SUCKER PUNCH CENTURY RIDE Saturday, April 25, 2015 Registration: Tear off & mail this form to the address below. Entry form must be received by April 11th to receive discount & be guaranteed an event t-shirt. On-site registration begins @ 7:00am. Start Time/Location: Start & finish @ Gear Up Cycles, 102 N. 15th St, Murray KY (Corner of 15th & Main St.) 100 mile ride begins @ 8:00am, 60 mile ride begins @ 8:15am, 30 mile ride begins @ 8:30am Proceeds: Murray State University Cycling Team Additional: Food, beverage & toilet facilities will be available on-route @ rest stations. Sag support provided. Post-ride meal for all cyclists. Information concerning route information & directions at www.gearupcycles.com. (DETACH HERE) -------------------------------------------------------------------------------------------- ENTRY FORM PLEASE PRINT CLEARLY NAME:___________________________________________________________ AGE (if under 18)______ EMAIL:___________________________________________________________ GENDER: M F MAILING ADDRESS:__________________________________________________________________ PHONE:______________ EMERGENCY CONTACT(Name & phone#)____________________________________ REGISTRATION: (select one) ____ ($30) Individual Pre-Reg by April 11 (will receive a free event T-shirt.) ____ ($40) Individual Day-of Reg (t-shirts while supplies last) ____ ($5) Individual under 18 (pre-reg by April 11 to receive a free event T-shirt) ROUTE SELECTION: ____30 Miles ____60 Miles SIZE(S) & QUANTITY OF SHIRT(S): (adult sizes) ____S ____M ____L ____XL _____XXL _____100 Miles Make Check Out to: Gear Up Cycles Mail to: Gear Up Cycles 102 N. 15th St. Murray, KY 42071 Extra Shirts: _____ X $15 = _________ PARTICIPATION ACKNOWLEDGMENT OF RISK AND RELEASE: In consideration of the services of Gear Up Cycles, LLC and Murray State Cycling Team, their agents, owners, officers, sponsors, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows: I acknowledge that bicycling entails known and unanticipated risks which could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of these activities. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless all sponsors and organizers, individuals or organizations, from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity, including any such claims which allege negligent acts or omissions of said individuals or organizations. I further certify I am willing to assume all costs that may be created, directly or indirectly, by any such injury or damage. I acknowledge that I am responsible for obeying all traffic laws and I am agreeing to wear a bicycle helmet while participating in this event. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms. Signature of Participant: ________________________________________________________ Date: ____________________ Signature of Parent/Guardian (if cyclist is under 18) _______________________________________________________________________ ALL PARTICIPANTS MUST WEAR A HELMET & OBEY ALL TRAFFIC LAWS!