(One person to a form. Form may be duplicated)

Name:

Street:

City: State: ZIP:

Phone: Date of Birth: Sex: Male Female

Emergency Name:

Emergency Phone:

eMail Address:

Do you plan to stay at a downtown hotel? Yes  No      Are you bringing your family?  Yes  No

All riders will be required to wear helmets!

RELEASE Please read carefully and sign.

        I understand that bicycle riding is potentially hazardous and involves a certain degree of risk that may result in injury or death. In consideration of the benefits to be derived after carefully considering the risk involved, I am voluntarily entering into these activities with knowledge of such danger recognizing that participation in the Chattanooga Bicycle Club, Inc. (hereinafter “Club”) 3-State 3-Mountain Challenge is voluntary. I hereby accept any and all risk of injury or death. In consideration of being permitted to participate in this activity, I, for myself, my spouse, legal representatives, heirs, and assigns, hereby release, waive, indemnify and hold harmless, and discharge Club, its trip leaders, coordinators, sponsors, representatives, officers, directors, employees, volunteers and any other person associated with such activity, from all liability to me, my spouse, legal representatives, heirs, and assigns, for any and all damage, any claim for damages resulting therefrom, on account of injury to my personal property, or my death, whether caused by negligence of Club or otherwise while I am taking part in this activity.

    I understand that bicycle riding is physically strenuous and I should not participate in a Club activity unless I am medically, physically, and mentally able. I assume all risks associated with participating in a Club event including, but not limited to, falls, contact with other participants, the effects of weather on trail or road conditions, traffic, and conditions on roads or trails. By signing this document, I certify that I have read and understand the importance and significance of it; and fully agree to all of the terms and provisions, and the release of liability.

Signature ________________________________________________________ Date

Signature of Parent or Guardian if under 18 ___________________________________________Date
(Must be accompanied by adult if under age 16.)

Please fill out and print the form, read & sign the release.
Make checks payable to: CHATTANOOGA BICYCLE CLUB
Send to:
Chattanooga Bicycle Club
attn: century
PO Box 11495
Chattanooga, TN 37401

Must be postmarked by April 21, 2008.

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