HEAVENLY HUNDRED
AUGUST 18, 2007
PRE-REGISTRATION FORM
(For printing and mailing)

For more information, call (931) 381-4235
or email us at info@columbiacyclingclub.com 

Complete registration form with check and return to:
Columbia Cycling Club
1116 W. Seventh St., PMB# 127
Columbia, TN  38401

Name:                                                                                                                       

Address:                                                                                                                    

City:                                                                  State                   Zip                       

Phone:                                                                  Age:                                  

I intend to ride                         33 miles                        66 miles                          100 Miles

T-Shirt Size (circle one)

Include check for $25, payable to Columbia Cycling Club.  Mail to the above address by August 12 (postmark).  See Active.com for registration through 8/17/2007.  Registration price on day of event is $30.

Waiver
Release of Claims

In consideration of your acceptance of this registration, I hereby for myself, my heirs, and my executors and administrators waive and release any and all rights and claims for damages I may have against the Columbia Cycling Club, Maury County Convention & Visitors Bureau, and any and all other sponsors or coordinating groups.  I also release the above named for all claims of damages, or death sustained as a result of my traveling to and from my participation in said event.  I attest and verify that I am physically fit and my bicycle is in excellent mechanical condition.  I also agree to read the safety rules and health tips in the SMTC brochure (that will be available at registration) and sign the related waiver prior to my participation in this event.  I acknowledge I have read and fully understand my own liability and do accept the restrictions.

Name (Print):                                                                                                             

Signature:                                                                                                                  

If participant is a minor, please complete the following:

                                                                                                                                 
                                 Name of Parent or Guardian (please print)

                                                                                                                                 
                                 Signature of Parent/Guardian (if 18 or younger)