Century Bike Rides Registration Form

October 6, 2012

Indian Valley Century Bike Rides

Registration Form

Last Name: First Name:


Mailing Address:

City: State: Zip Code:

Home Phone:

Emergency Contact Phone:


Metric 100 $50 per person:

Age 16 or under $25 each:

Mile 100 $50 per person:

Age 16 or under $25 each:

Total Amount: $

Release Statement: I hereby release all sponsors and organizers of Indian Valley Century Rides as well as all units of Government and Private landowners whose jurisdiction this event shall pass through, all agents and officers of the above, and all parties associated with this event, for the responsibility for injury to myself, and my equipment sustained during the course of this event. I also agree to abide by the rules established for the Indian Valley Century Rides and those established for traffic laws of California.

Rider’s Signature:

Parent or Guardian Signature:

If the rider is under 18 years old.

A parent or guardian must sign the release for riders younger than 18 years of age and must accompany riders that are under the age of 16 years. Each rider must sign an entry form.

Mail with payment to:

IVCC P.O. Box 516 Greenville, CA 95947