SEQUATCHIE VALLEY CENTURY

ENTRY FORM

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

Street:

City: State: ZIP:

Phone: Age: Sex: Male Female

Emergency Name/Phone:

Email Address:

Ride Option Choice: 100 mile 62 mile 25 mile 

T-shirt size: Medium Large X-Large XX-Large
(NOTE: T-shirt may not be available on day of ride it not ordered by 9/27/02)

Entry Fee:

All riders will be required to wear helmets!

RELEASE Please read carefully and sign.

        In consideration of the acceptance of this application, I hereby, for myself, my heirs, executors, administrators and assigns, and anyone entitled to act on my behalf, release and discharge the Chattanooga Bicycle Club, plus sponsors, their representatives and successors, directors, officials, employees and volunteers, from any and all claims of injury or damages suffered by me as a result of my participation in or traveling to or from the Chattanooga Bicycle Club's Sequatchie Valley Century.
      I know that bicycle riding is potentially hazardous. I should not enter the Chattanooga Bicycle Club's Sequatchie Valley Century unless I am medically able and properly trained. I assume all risks associated with riding in the Chattanooga Bicycle Club's Sequatchie Valley Century, including but not limited to, falls, contact with other participants, the effect of the weather, traffic, and conditions of the road, all such risks being known and appreciated by me. I realize that bicycling is a strenuous activity which requires proper physical conditioning. I hereby certify that I am in such physical condition and good health.

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

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