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ENTRY FORM
2001 one entrant per form REGISTER
EARLY... win prizes
Print form and mail
with registration fee (check payable to: PMVFR Century) to:
PMVFR Century, 932 Valley Grove Road, Remlap AL 35133-3160
(circle choices)
Event: 100M 100K 25M - Pine Mtn 25M
10M 5M
Fee
included: $___
Entrant: Adult Family #___ (include one form for each member)
Student Kid
T-shirt size adult: medium large X-large
XX-large
Post-ride meal: BBQ Pork BBQ Chicken
Spaghetti-meat Spaghetti-NO meat
Camping: ___ tent(s) RV:___ Friday evening meals:___
$5ea
___________________________________________________________________M_F
First Name
Middle Initial Last Name
Age
______________________________________________________________________
Street Address
City
State Zip
(___)__________(___)___________(___)______________________@_____________
Phone Home
Work
Fax
email
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY
In consideration of being permitted to participate
in any way in the Pine Mountain Volunteer Fire & Rescue Dept. (PMVFR) sponsored event
and activities I, for myself, my personal representatives, assigns, heirs and next of kin:
1. Acknowledge, agree and represent that I understand the nature of this event and that I
am qualified in good health, and in proper physical condition to participate in such
event. I further acknowledge that the event will be conducted over public roads and
facilities open to the public during the event and upon which the hazards of
traveling
are to be expected. I further agree and warrant that if at any time I believe conditions
to be unsafe, I will immediately discontinue further participation in the event.
2. Further, I hereby agree to abide by the rules and regulations governing this event and
elect to participate at my own risk and in consideration for being allowed to participate
do hereby release and discharge the PMVFR, its assigns, officers, agents, employees,
officials and their successors, event sponsors, the
municipalities and other jurisdictions in which the event is held, and all other
organizations and persons connected with the event from any and all liability (including
death) that may be received by me and from all claims and demands to my personal property
growing out of or resulting from my participation in the event. I also understand that the entry fee paid by me is non-refundable.
All riders must at all times wear a buckled ANSI/SNELL approved helmet during
participation in this event!
Riders
19 and under must have parental consent, 16 and under must ride with an adult.
I HAVE CAREFULLY READ AND UNDERSTAND THIS WAIVER
___________________________ _____________________________________________ ______________
Participant Signature
Participant/Guardian Signature for Participants under
19
Date
| FEES
Sent |
By Sep 8 |
After
Sep 8 |
|
| Adults |
$25 |
$30 |
|
| Family
(max. 4 shirts, 4 meals)
|
$70 |
$75 |
|
| Students
(Full time - ID required) |
$15 |
$20 |
|
| Kids
under 10 (kid's meal) |
$12 |
$15 |
 3/5/00 |
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