Sunday, April 17, 2011 -- Bruceton Mills, WV / Big Bear Lake
Big Bear Lake Bike Classic - WVMBA #2
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EVENT CONTACT: Mark Schooley (phone) 304-379-4382, (e-mail) Bentfattire@aol.com
FEE . . . Kids Race $5.00, WVMBA members $30.00, non-members $35.00
PAY/MAIL TO . . . Big Bear Lake Camplands, 450 Big Bear Lake Road, Bruceton Mills, WV 26525
WVMBA ACCIDENT WAIVER & RELEASE OF LIABILITY -- RACE REGISTRATION FORM ** This form must be read carefully, filled out completely and signed by each racer (including children). ** EVENT NAME: Big Bear Lake Bike Classic - WVMBA #2 DATE: ____________________________ WVMBA MEMBER? [ ] Yes [ ] No Race Number: ___________________ (Leave blank if not yet assigned) NAME: ___________________________________________ AGE: ________ DOB: _______________ PO BOX OR STREET: _____________________________________________________________________ CITY: _______________________________________ STATE: __________ ZIP: _______________ PHONE# (___________)________________________ E-MAIL ADDRESS: __________________________________________________________ EMERGENCY CONTACT: _______________________________ PH# _______________________________ WOMEN'S Point Series Classes: [ ] Pro/Expert [ ] Vet (35+) [ ] Sport [ ] High School (15-18) [ ] Women's Beginner MEN'S Point Series Classes: [ ] Pro/Expert [ ] Grand Master (55+) [ ] Sport Masters (45+) [ ] Expert Masters (45+) [ ] Sport Vet (35+) [ ] Expert Vet (35+) [ ] Sport (19-34) [ ] Expert Junior (18-Under) [ ] Men's Beginner [ ] Clydesdale (200lbs+) [ ] High School (15-18) [ ] Single Speed Open [ ] Junior (14-Under)
Entrants Signature:_________________________________________________________________
Date: ______________________________________
(Note: If entrant is age 17 or under, Signature of Parent or Guardian is required below) The undersigned parent and natural guardian or legal guardian does hereby represent that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, claim or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.
Signature of Parent or Guardian: _____________________________________________________
Date: ______________________________________