GITAP 2004 Entry form

Complete and sign. One form per rider. Copies are acceptable.

Name______________________________________________________________________M/F______Age_______

Address________________________________________________________________________________________

City_______________________________State_____________Zip________________

Phone____________________________E-mail________________________________________

Emergency Contact Name___________________________________________________________Phone__________________

T-shirt (included in fee) size:  M  L  XL  XXL

Check here if you prefer vegetarian meals. ___

Check here if you plan to use motels or cabins for the entire ride at your own expense. ___ If so, we will send you our "GITAP motel registration" package.

Fees:
Ride Fee: $310 (If you would like to be an League of Illinois Bicyclists (LIB) member, check here. ___  $_______
                $290 (for current members of LIB)                                                                                             $_______
Extra T-shirts (indicate quantity and sizes): M___ L___ XL___ XXL ___ (Total at $10 each)                   $_______

                                                                                                                                                 Total           $_______
Make checks Payable to League of Illinois Bicyclists and mail to:
GITAP
Chuck Oestreich
816 - 22^nd St
Rock Island, IL  61201

Release of Organizers and Sponsors:

In signing this for myself or the named participant, I understand that participation in the Grand Illinois Trail and Parks (GITAP) ride, as in any bicycling or athletic event, may involve hazardous activity. I agree to accept and assume all risk and danger incidental to the GITAP ride occurring prior to, during, or subsequent to the actual ride, including but not limited to the risk of physical injury, mental injury, emotional distress, trauma, death, contact with other participants, equipment failure, inadequate safety equipment, the effect of weather including extreme temperature or conditions, traffic, contact with motor vehicles of all types and descriptions, collision with other riders, pedestrians, animals, fixed objects, or conditions of the road. I waive any and all specific notice of the existence of the risks and hazards. I, for myself, and anyone acting on my behalf, agree to absolve all organizers, sponsors and their representatives, singly or collectively, of all blame for any injury, misadventure, harm, loss, or inconvenience suffered as a result of taking part in the GITAP ride or in any of the activities associated with it. I agree to obey all traffic laws, signs, and signals. In addition, I hereby grant permission to the organizers of the GITAP ride and its authorized agents to use my name and photographs, video tapes, motion pictures, recordings, and any other record of my participation in this event for any purpose.

I agree to the above waivers and disclaimers.

Signature: __________________________________________________ Date: __________________

Signature of parent or guardian for rider 17 years of age or under: _________________________________________________________

THIS WAIVER MUST BE SIGNED

Your cooperation is important - we must do our part to "share the road"!

I agree not to ride two or more abreast when it is impeding traffic. I agree to follow all other rules of the road, which apply to both cars and bicycles.

Signature: _______________________________________________