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Sunday, April 7, 2002 -- Waverly, WV
2002 Challenge at Mountwood Entry Form
(iPO Event Id#: 4782)
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NAME______________________________________________________
STREET____________________________________________________
CITY_______________________________STATE_____ZIP__________
PHONE#____________________________________________________
AGE ON 12/31/2002___________ MALE_______ FEMALE_______
Race Class
50K: 40K:
PRO/EXPERT ___ SPORT ___
VETERAN EXPERT(35+) ___ VETERAN SPORT(35+) ___
JR EXPERT(18-UNDER) ___ MASTERS(45+) ___
JUNIOR SPORT(15-18) ___
15K: CLYDEDALES(200lbs+) ___
JUNIOR (14-UNDER) ___
BEGINNER ___
RELEASE AND CONSENT:
In consideration of the acceptance of my application and in signing
the release and consent for myself or for the named entrant (if the
entrant is under the age of 18), I acknowledge that I understand the
intent hereof, that I hereby agree and will hold harmless the Challenge
At Mountwood Committee and WCP&RC, its individual members, its officers,
its support entities, and sponsors respectively, singularly and collectively, from
and against any blame of liability for any injury, misadventure, harm,
loss, inconvenience or damages suffered or asscociated therewith. I
also hereby consent to and permit emergency treatment in the event of
injury or illness. I shall abide by traffic laws and regulations and
practice courtesy and safety in cycling. Helmets are required for all
races.
_____________________________________________________
SIGNATURE OF ENTRANT DATE
_____________________________________________________
PARENT/GUARDIAN IF UNDER 18 YRS OLD DATE
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