2009 PARADISE LOOP RIDE REGISTRATION FORM
Rider's Name:_____________________________ Age ____
Address: ________________________________________
City, State & Zip: ___________________________________
Phone: _________________ E-mail: __________________
Emergency contact: __________________________________
Vegetarian meals? ____ Do you plan to camp with us Saturday night? ____
Will you need a ride back to Shonto after the ride? ____
Do you have any medical problems, medication allergies or take any medications that we should know about? ____________________________________________________________________________________________
REGISTRATION: Adult registration ($50) ___ Student registration ($20) ___ Please make checks payable to Y.E.S.
WAIVER & RELEASE:I understand that there are certain dangers inherent in the sport of cycling and I fully assume and accept these risks. I understand that participation in this event requires use of a CPSC-certified helmet. In consideration of Youth Empowerment Services for Dine' Bikeyah, Inc. (Y.E.S.) accepting my application for entry into the 2009 Paradise Loop Ride, I hereby waive, release and discharge Y.E.S., its employees, the Paradise Loop Ride organizers, sponsors, volunteers, supporters and participants from any claims for personal injury, property damage or death resulting from my participation in this event. I certify that my bicycle is suitable for safe use in this event, that I am in good physical condition and that I am able to participate in this event. I consent to emergency medical care if injured or ill. I have read this waiver and release and fully understand its terms, and agree that is shall be binding on my heirs and assigns.
______________________________ ___________
Rider's Signature Date
[Parent/Guardian must sign for riders under 18 years old.]
