Print out and mail this
completed registration form, waiver, and
check to:
MILEPOST ZERO BICYCLE CLUB
P.O. Box 1693
Waynesboro, Va. 22980-2118
PLEASE PRINT CLEARLY and
USE A SEPARATE FORM
FOR EACH
PARTICIPANT. You must sign the Release and
Waiver Form on the BACK of
this application as well!
Last Name:
___________________First Name:_______________
Address:
________________________________________________
City:
______________________State:_________ Zip: ___________
Daytime Phone #: _____________
Cell Phone #* :
_____________
* If you plan on bringing
cell phone on the ride
E-mail**: ___________________________
**E-mail will be used for
registration confirmation only
Sex: M___ F____ Age________ Is this your
FIRST Century? Yes_____ No ______ (we like to recognize
all 1st timers!)
Emergency contact &
phone #: _______________________________________________
Distance you plan to
ride: _____ Century (100 miles)
_____ Shorter Ride Option (65 miles)
Registration Fee (*postmarked date):
_____ $10 on or before 8/17/07* for Milepost Zero Club members
_____ $20 on
or before 8/17/07* for non club members
_____ $25
after 8/17/07* for all riders (through 9/1/07: You need
to
make sure these arrive to our post office box by Sat. the 1st)
_____ $30 for
all applications on 9/02/ 07 (day of the 2007 event)
Tour de Valley T-Shirts
You can purchase a Tour
de Valley T-shirt for an additional $10.00. However due to circumstances
beyond our control, we cannot guarantee T-shirts
will be available for those who register after
8/10/07.
_____ $10.00 Tour de Valley LONG
SLEEVE
T-SHIRT
Size S
M L XL
_____ Total amount
enclosed
Release and Waiver on
backside of form must be completed and signed!