One Helena Hundred Ride Entry Form
Saturday, July 21, 2001
Pre-registration deadline – must be postmarked by July 6. Save $$$ – REGISTER EARLY! Participants will receive registration confirmation upon receipt of entry form.To enter, please print and complete this form. Return the completed form along with a check or money order payable to Helena Bicycle Club. One rider per form.
Please print legibly.
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First Name |
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Address |
Sex |
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City |
State |
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Phone |
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Emergency Contact – Please list someone NOT on the century ride.
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Name |
Relationship |
Phone |
Registration Fees (please check appropriate boxes) – Your registration fee includes a t-shirt, lunch, and rest stop refreshments.
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o One Helena Hundred Fee (non-club member, over the age of 16) $30.00 |
$ |
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o One Helena Hundred Fee (Helena Bicycle Club member, over the age of 16) $25.00 |
$ |
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o One Helena Hundred Fee (youth, 16 years or under) $15.00 |
$ |
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o Helena Bicycle Club Membership (become a member now and pay discounted member registration fee) $15.00 |
$ |
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o Late Fee (must be included with registration fee if registering after July 6) $5.00 |
$ |
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TOTAL Check or money order for this amount should be enclosed |
$ |
Please check appropriate boxes. T-shirt Size, Adult: o Medium, o Large, o X-Large, or o XX-Large
I plan on riding: o 100 miles or o 100 kilometers (approx. 62 miles)
Representation and Acknowledgement:
I hereby represent that I am in good physical condition for this ride. I understand the route is challenging and not chosen for its safety. I understand that this is a non-competitive event and not a race. I further represent I have the ability and equipment to handle the route and any weather conditions. I agree to wear an ANSI-approved bicycle helmet, and I understand a rear-view mirror is recommended.
Release from Liability:
In consideration of the acceptance of the registration, by signing this release (parent or guardian, if registrant is under 18 years of age), I hereby release for myself and my kin, and waive any claims of action against the Helena Bicycle Club, its officers, directors, members, agents and all other persons or entities from all liability arising out of any injury to persons or property, and any loss, damage or expenses arising out of my participation in this ride.
Application is not valid without signature!
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Signature of Participant |
Signature of parent or guardian, if participant under 18 years of age |
Date |
Mail form and payment to:
HELENA BICYCLE CLUB, P.O. BOX 4682, HELENA, MT 59604-4682
