SATURDAY SEPTEMBER 20, 2014      Sauk Prairie, WI

NAME:  -----------------------------------------------------------------REFERRED BY:----------------------------------------------

ADDRESS: -----------------------------------------------------------------------------------------------------------------------------

CITY ----------------------------------------------------------- STATE ------------------------------    ZIP ------------------

TELEPHONE (    )       -                                     E-MAIL ADDY:-------------------------------------@----------------.  -------

ROUTE I WANT TO RIDE (circle)   5 mile    20 Mile    40 Mile    60 Mile  (++ option)  [ALL route miles are approximate)  

I am a member of (team name):_____________________________________________

 

Shirt size:          Sm< >      Med < >     Lrg < >     XL < >     Other<________>

 

For credit card payment go to active.com   (find activities near you)

                                             OR

If by check,please (to help keep our 1st annual start-up expenses low) make checks payable to:

TOUR de DAM (memo notate UW Carbone Cancer Research Center)

Print and send to:                                  

TOUR de DAM

c/o Gary Moddes P.O. Box 63  Prairie du Sac, WI 53578-0063

Enclosed amount: $________________ Team name_________________________________

NO FEE REFUNDS WILL BE ALLOWED.

 

 

NOTE:

I, the undersigned, agree to release all parties including, but not limited to any organizers, volunteers, sponsors, officials and other personnel associated with the 2014 TOUR de DAM bicycle tour. I understand that wearing a helmet is required and that all rules of the road must be followed. I agree to follow all instructions given by ride officials while participating in the tour.

 

SIGNATURE:_______________________________________________

DATE:     /    /