Bonners Ferry Rotary Club

KOOTENAI RIVER RIDE

PRINTABLE RIDER REGISTRATION

I am riding...	___ 20k   ___ 53k   ___ 95k	Price	Subtotals
How many...	___ Individual: (Fee includes one T-shirt)	$20.00	__________
	___ Family (up to 4):  # _____ (Fee includes two T-shirts each)	$40.00	__________
Name: _________________________________________________________ Sex/Age: _________________________________________________________ Address: _________________________________________________________   _________________________________________________________ Emergency Contact: _________________________________________________________ Emergency Phone: _________________________________________________________ e-mail: _________________________________________________________ Signature: _________________________________________________________ Method of Payment (Sorry, can not accept credit cards)   Check #_____   Money Order ___		Additional Event T-Shirts $15.00 each Quantity Size ___ Small ___ Medium ___ Large ___ X-Large ___ XX-Large Total Amount Enclosed: $________
Required Waiver/Release Form: I verify that I understand an ANSI approved helmet is required to be worn at all times while riding in the Kootenai River Ride. I have read, understand and agree to abide by the safety precaution requirements and all other rules presented to me. I agree to indemnify and hold harmless the Bonners Ferry Rotary Club and all of its sponsors from all cost, exposure, and liability arising out of my participation in the ride. I hereby waive all claims for damage or loss to my person or property which may be caused by any act or failure to act by the Bonners Ferry Rotary Club, its officers, agents or employees arising directly or indirectly from my participation in the ride. I give my permission for medical release should I be involved in an accident or a health-damaging situation requiring medical treatment. I grant permission to use any photographs, motion pictures, recordings or any other records of this event for any legitimate purpose. Signature:   ________________________________________________________    Date: __________________________ If under 18 years of age, you must obtain the signature of a parent or guardian                                                                              Signature of Parent/Guardian: ___________________________________________
Mail registration and payment by September 15, 2006, to: Bonners Ferry Rotary Club/ Kootenai River Ride PO Box 1921 Bonners Ferry, ID 83805