York Lucky 13 Ride

Official Entry Form

To enter, complete this form and return it along with your check or money order payable to York Volunteer Fire Department. Registration is open until 9:30 AM August 28, 2010 at York Fire Hall.

Lucky 13 Ride (If under age 12, accompanying adult information is required)

1. Youth Last Name First Name Age Gender
2. Youth Last Name First Name Age Gender
3. Youth Last Name First Name Age Gender

Adult Riding with or without Children

1. Adult's Last name First Name Age Gender
2. Adult's Last name First Name Age Gender
Address      
City State    
Phone  Daytime:                                       Evening Email    

Emergency Contact- Please list someone NOT on the ride.

Name Relationship Phone

Registration Fees -Each rider will receive rest stop refreshments, T-shirt, and lunch at York Bar

(     ) Adult Fee.......................................................................................................................................................$35.00 $                           
(     ) Youth Fee ............................................................................................................................................................$25.00 $                                
(     ) Family (up to 4 riders) ............................................................................................................................................................$55.00 $                                 
TOTAL .........( Check or money order payable to York VFD) $                              

Enter quantity in appropriate box for T-shirt size:  Child   Small (6-8)  (         )    Medium (10-12)  (        )    Large (14-16)  (        )       

Adult     Small (          )    Medium (       )    Large (       )    X-Large (       )

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 York Fire Service Area, its officers, directors, members, agents, and all other persons or entities from all liability arising out of any injury to person or property, and any loss, damage or expenses arising out of any participation in this ride.

____________________________________________________    _________________________________________________________    __________________

Signature of Adult                                                                                        Signature of parent or guardian if rider is under 18                                       Date

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Signature of Adult                       Mail completed form and payment to: York 38 Special Ride, C/O York VFD, 6042 Nelson Road, Helena, MT 59602