Name: _______________________________  One form per rider! 
Copy form as needed!

Address: ________________________

City: _______ State: ____Zip: ________

Phone: ______________

Emergency Name & Phone: 

_________________
_________________

_____________________________________

Amount enclosed        $___________________

Be sure to read and sign the release!

RELEASE FORM
In signing this entry and release form for myself or for the named applicant (if that applicant is under the age of 18), I hereby agree to and make the following representations: I know the risks associated with bicycling events and I willingly accept them. I am covered by my own medical insurance or otherwise accept full responsibility for any and all medical expenses I may incur as a result of my participation in this event. I will permit emergency treatment in the event of injury or illness. To my knowledge, I have no physical or mental conditions which would endanger myself or others by my participation in this event. I have properly maintained my bicycle and related equipment so as to insure my safety and that of other participants. I agree to wear an ANSI/Snell approved bicycle helmet will protect against serious head injuries. I agree to assume all responsibility and liability for the selection of such a helmet. I agree to use safe bicycle practices at all times while participating in this event. 

I understand and agree to release for myself and my heirs, the Rapid Wheelmen Inc. (members and officers), and any other event sponsors, organizations, and promoting organizations, be they individuals or organizations, singly and collectively of all blame for any injury, death, loss, damages, or inconveniences suffered by me while traveling to, from, and while participating in this event. I agree that it is my sole responsibility to know the Michigan Vehicle Code and any other special rules pertaining to this event as set forth in the event materials. I agree that the above representations are contractually binding and not mere recitals. This contract may not be modified orally and a waiver of any provisions contained herein shall not be construed as a modification of any other provisions herein. I have read this contract, understand it and agree to its terms. 

Signature of Participant ___________________________________  Date ________ ________

Adult Signature if Participant under age 18_____________________ Date _______________