1st Annual Millerstown Community Park Bike Tour Registration Form

Ghost Rider -25K- 50K-100K Rides

Saturday, June 25, 2011

Millerstown Community Park

Millerstown, PA
Name: _______________________________________________________
Address: _______________________________________________________
_______________________________________________________
Phone: __________________ Email ______________________________

Emergency
Name and Telephone: ____________________________________
Contact

Fees: Pre-reg. $20 by 6/18/2011 ________ Day of Ride $25 ________

I Pledge to raise at least $100, due by day of Ride ________
(Waive my registration fee)
Make checks payable to: Millerstown Recreational Committee
I plan to ride the: Ghost Rider _____ 25K _____ 50K _____ 100k _____

T-shirt Size: Sm.____ Med. ____ Lg. ____ X-L ____ XXL_____

Free T-shirt to the 1st 100 pre-registered participants

I understand and agree that the riding of a bicycle or otherwise participating in a bike ride event contains inherent and other
risks that could lead to serious injury or death, especially when riding or standing on or adjacent to public roadways traveled
by motor vehicles. I understand that Millerstown Recreational Committee (MRC), as sponsor of this event, is not accepting
any responsibility for protecting any rider or other participant from any of the risks associated with this event and that I am
solely responsible for my own safety and the safety of any of my children participating in the event, and for following all
rules of the road and traffic laws. In addition, I agree to wear a helmet. Intending to be legally bound, I, for myself, my heirs,
executors, administrators, and anyone else who can claim on my behalf or with respect to any injury of me or my children
who are participating, hereby agree not to sue and release MRC, its directors, officers, employees, and/or volunteers, and all
boroughs and townships from any and all liability related to injury, property loss or otherwise related to my or any of my
children’s participation in this event, regardless of any negligence on the part of any of them, and whether such claims are
now known or unknown, anticipated or unanticipated. I further grant full permission to MRC to use any photographs or any
other record of this event, and information about my participation or that of my children, therein for any purpose. I attest that
I am at least 18 years of age and am medically able and properly trained to participate in this event. This must be signed in
order to ride. Registrations for minors will be accepted only with a parent’s or guardian’s signature. I have signed the
registration form on the reverse side of this panel.

Signature of Participant: _____________________________ Date:________

*If under 18, Parent/Guardian of
_____________________________ Date:________
minor must sign

To register, print this page, and mail to: C/O Scott Sanderson, 202 Old Ferry Rd.
Millerstown, PA, 17062