REGISTRATION FORM
1. SELECT YOUR EVENT(S)
| Check | Event | Start Time |
Before 9/2/2007 |
There- after |
| [ ] | 5K Race | 7:30 | $ 20.00 | $25.00 |
| [ ] | 3 Mile Walk | 7:30 | $ 6.00 | $ 8.00 |
| [ ] | 100 Mile Bike Tour | 8:00 | $20.00 | $25.00 |
| [ ] | 66 Mile Bike Tour | 8:00 | $ 20.00 | $25.00 |
| [ ] | 33 Mile Bike Tour | 8:00 | $ 20.00 | $25.00 |
| [ ] | 10 Mile Bike Tour | 8:00 | $ 6.00 | $ 8.00 |
| [ ] | Events for the Challenged | 10:00 | $ 6.00 | $ 8.00 |
| [ ] | Kids Events ** | 9:00 | $ 6.00 | $ 8.00 |
*Do more than one event! Pay for your most expensive event and do any other event FREE!
**Kids events include a Fun Run, Obstacle Course, and Jr. Bike Rodeo!! Kids are encouraged to do all events. Bring a bike and helmet to do the bike rodeo The Fun Run starts at 10:00 a.m. Trophies awarded to the fastest boy and girl in each grade from K-8. Think you're the fastest in your grade???
2. COMPLETE THIS INFORMATION
Name: ____________________________________________________
Address: __________________________________________________
City/State/Zip: _______________________________________________
Phone: ___________________________________________
E-mail: ________________________________________________
Age: ______________ Grade: ________________ Male _____ Female _____
T-shirt size: _____ Youth (10-12) ____ Youth (14-16)
_____ Adult Medium
_____ Adult Large _____ Adult XL
Amount enclosed: $________ Make checks payable to: Lafayette Rotary Club.
Support your school (please check one): _____ Fairlane _____Central Elem.
_____ RBS Elem.
_____ RBSHS _____ MCJHS _____ MCHS
_____ Westside _____ Lafayette Elem.
Support your teacher (please name): _______________________
3. SIGN THIS WAIVER
In consideration of being allowed to participate in this event, I, for myself, executors, administrators and child (if signing as a parent or guardian), do hereby release and promise not to sue the hosts, sponsors, or any cooperating agencies, individuals, or employees for any claim or injury that may result from my participation in this event. I know that these events are potentially dangerous, and I have full knowledge of all risks involved. I am physically fit and sufficiently trained to participate in this event. I hereby grant full permission to any and all of the above parties to use any photographs, videotapes, motion pictures, website images or any other record of this event.
Participant (or parent/guardian if child under 18) __________________________________
Date Signed: _______________________
4. SEND IN THIS FORM
MAIL THIS FORM WITH ENTRY FEE TO:
Debbie Mason
P.O. Box 10
Lafayette, TN 37083
Please make checks payable to: Lafayette Rotary Club.
OR .................
TAKE THIS FORM WITH ENTRY FEE TO: Any local branch of Citizens Bank, GreenBank or Macon Bank and Trust.
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