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Page 1 of 6
2015 Will B. Rolling to Ben Bikin’ Bike Tour Paper Registration Form
Name
Birthdate _____/_____/_____ Gender O Male O Female
Address
Occupation
City
Home Phone
State
Zip
Work Phone
E-Mail
Fax
Alternate E-Mail
(please provide an additional e-mail address different
from the one above if possible)
Cell Phone
(For overwhelming safety reasons we strongly suggest you
carry a cell phone during the tour at all times. If you don't
have one print "NO CELL")
Distribute my contact information to other participants (your contact
information will only be distributed to other participants and not to anyone else)
T-Shirt Size
(included with registration)
S
O
M
O
L
O
XL
O
XXL
O
O Yes
O No
XXXL
O
Food considerations you may need (food allergies, lactose intolerant, vegetarian/vegan, Kosher, etc.)
Additional considerations you may need (special lodging requirements, travel plans, transportation of bike trailers or
shipping containers, disability accommodations, etc.)
How did you hear about Will B. Rolling to Ben Bikin’ Bike Tour?
What phrase(s) would you type into an internet search engine such as Google and Yahoo to find us? (this is to
optimize our internet search results)
111 Milwaukee St
Sparta, WI 54656
[email protected]
(800) 354-2453
www.willtoben.com
Page 2 of 6
EMERGENCY CONTACT INFORMATION
Name
Phone Number
Relationship
PERSONAL RIDING AND EQUIPMENT
What is your average riding pace?
mph
This is to ensure you are fully supported during the entire tour.
What type of bicycle do you plan on riding?
Trikes (bicycles with three wheels) are not allowed on our events due to our inability to easily and quickly transport
them in any vehicle or aboard an Amtrak train.
O Upright road bike
O Hybrid
O Mountain bike
O 2-wheel recumbent
O Tandem
O Upright folding bike
O Other: (please specify)
Wheel Size and Valve Stem Type
Please indicate the size of your wheels and valve stem type to ensure we stock the proper tubes for on road support.
Wheel Size
O 700c
O 650c
O 27"
O 24"
O 26"
O 20"
O 29"
O 16"
O 12"
Valve Stem Type
O Presta
O Presta (long stem)
O Shrader
O Other: (please specify)
Do you plan on using a personal Global Positioning System (GPS) unit to navigate while riding?
Route dataset files will be available for download to participants who own a personal GPS unit. If yes, please specify
the brand and model (example: Garmin Edge 800, Garmin eTrex Legend Cx, Garmin GPSMap 60CSx, etc.)
O
O
O
Yes:
Maybe
No
What is your handlebar diameter?
This is to ensure you have the appropriate handlebar mount if we provide individual GPS units.
O 1” (25 mm)
O 1 1/4" (32 mm)
O Other: (please specify)
Do you plan on having your own additional on road SAG support?
Yes
O
Maybe
O
No
O
111 Milwaukee St
Sparta, WI 54656
[email protected]
(800) 354-2453
www.willtoben.com
Page 3 of 6
TOUR REGISTRATION
Will B. Rolling to Ben Bikin’ Full Tour Registration (Port Byron, IL to Sparta, WI)
Registration for each day includes camping-style lodging in the town you will bike from, breakfast, and food and on
road support the next day.
Early Bird
Starting May 1, 2015 Starting July 1, 2015
O Rider
$399
$419.00
$439.00
O Non-Rider
$219
$219
$219
*Registration form and payment must be postmarked no later than the cutoff date to qualify for reduced rate (i.e.
postmarked by April 30th to qualify for the early bird price of $399.00)
Will B. Rolling to Ben Bikin’ Partial Day Tour Registration
Registration for each day includes camping-style lodging in the town you will bike from, breakfast, and food and on
road support the next day. REGISTRATION FOR EACH DAY DOES NOT INCLUDE LODGING IN THE TOWN YOU WILL BIKE
TO!
O Rider - $89.00 each day
O Non-Rider - $44.00 each day
Yes
O
O
O
O
O
O
Maybe
O
O
O
O
O
O
No
O
O
O
O
O
O
Riding Day
Day 1: Port Byron, IL to Savanna, IL
Day 2: Savanna, IL to Platteville, WI
Day 3: Platteville, WI to Richland Center, WI
Day 4: Richland Center, WI to Reedsburg, WI
Day 5: Reedsburg, WI to Elroy, WI
Day 6: Elroy, WI to Sparta, WI
Days
Sun.
Mon.
Tue.
Wed.
Thu.
Fri.
PERSONAL TRAVEL AND LODGING
Please Indicate Where You Will Park During the Tour (if applicable)
O Sparta, WI
O Port Byron, WI
111 Milwaukee St
O Other: (please specify) _________________________
Sparta, WI 54656
[email protected]
(800) 354-2453
www.willtoben.com
Page 4 of 6
Nightly Lodging Plans
All baggage will be delivered to the main lodging site. You must let us know your lodging plans so we know what to
expect on the tour. Please indicate where you will be staying on which nights of the tour. (Individual hotel/motel/B&B
reservations must be made on your own. Those choosing to stay in optional lodging will also be responsible for the
transportation of the bag(s) to and from the main lodging site. Bags must be delivered back to the main lodging site by
the scheduled departure time the next morning.)
Main Lodging Site
Yes
No
O
O
O
O
O
O
O
O
O
O
O
O
Town
Days
Port Byron, IL
Savanna, IL
Platteville, WI
Richland Center, WI
Reedsburg, WI
Elroy, WI
Oct. 3
Oct. 4
Oct. 5
Oct. 6
Oct. 7
Oct. 8
EXTRA SERVICES AND MERCHANDISE REGISTRATION
All merchandise items will be delivered during the event. Prices listed include sales tax. All extra services and
merchandise items may also be added later at willtoben.com (subject to availability).
Motor Coach Transportation
BEFORE THE START of the tour
•
From Sparta, WI to Port Byron, IL
Includes bicycle and baggage transportation to Port Byron, IL, and motor coach transportation for you to Port
Byron, IL on Saturday, October 3rd, 2015.
Yes
O
Maybe
O
No
O
Pick Up Location
Sparta, WI - $99.00
Any other comments, questions, or suggestions?
111 Milwaukee St
Sparta, WI 54656
[email protected]
(800) 354-2453
www.willtoben.com
Page 5 of 6
AGREEMENT, WAIVER & RELEASE OF LIABILITY
I, the undersigned, know that WILL B. ROLLING TO BEN BIKIN’ (“the EVENT”) is a potentially hazardous activity and I attend it out of my
own free will and choice. In choosing to attend the EVENT and any related events, I fully accept and assume all risks, whether before,
during or after the EVENT and its related events. These include, without limitation, physical injury, mental injury, emotional distress,
trauma, sickness, illness, death, contact with other participants, equipment failure, inadequate safety equipment, the effects of weather
including extreme temperature or conditions, traffic, contact with other riders or fixed objects, the conditions off the road, camping, and
participating in events along the route. All risks are known and appreciated by me. I shall assume and pay my own medical and emergency
expenses in the event of injury, illness, or other incapacity regardless of whether I authorized such expenses.
I agree to abide by all of the EVENT rules, regulations, policies and procedures as published on the web site and/or as directed by the ride
director and that my participation in the EVENT may be temporarily or permanently terminated for any failure to do so. I realize that the
EVENT requires physical conditioning and I represent that I am in sound medical condition capable of participating in the ride without risk
to myself or others. I have no medical impediment, which would endanger others or myself. I understand and agree that a situation may
arise during the EVENT which may be beyond the control of the sponsors, promoters or organizers. I will be solely responsible for the
condition and adequacy of my bicycle, safety gear and riding equipment. I will ride safely within the limits of my own abilities, my
equipment and the riding conditions and in a manner so as not to endanger either myself or others. I understand that the specific routes
provided to me to follow during the EVENT are the proprietary, copyrighted, confidential intellectual property of the EVENT and are only
for my private, personal use during the event. I agree not to disclose any information regarding any route in any means - electronic,
printed, or otherwise. I agree that I will wear a Snell or ANSI approved bicycling helmet at all times while riding in the EVENT.
I grant the EVENT the unrestricted right, license, and authority to display, record, and/or otherwise use my image, voice, likeness and/or
any depiction of mine in whole or in part for any purpose at the EVENT's sole discretion, including, but not limited to, any account,
description, picture, video, audio, reproduction or other information related to the event.
Knowing these facts and in consideration of my entry acceptance, admission to and/or participation in the EVENT, I, for myself and anyone
acting on my behalf, release, waive, discharge, covenant not to sue and agree to hold the EVENT’s sponsors and participating clubs,
communities and organizations; the EVENT’s officials, emergency and support personnel, volunteers and their representatives; directors,
employees, representatives, agents, and successors of all of the above, harmless from any and all claims, demands and actions of any and
every kind I have, may have or may hereafter accrue against the released parties directly or indirectly arising out of or relating in any
respect to my attending or participating in the EVENT and its related events. My waiver and release of all claims, demands, actions and
liability shall include without limitation, any injury, damage or loss to my person or property which may be (a) caused by any act, or failure
to act, by the above-identified persons and entities or (b) sustained by me before, during or after the EVENT and its related events. I
further agree to indemnify and hold the parties released above harmless from any and all losses, damages, claims and expenses, including
attorneys’ fees, arising from or relating in any respect to my participation in the EVENT or its related events or my breach of this
agreement. If I am a minor, my parent or guardian also is signing on my behalf and we both agree to be bound by the terms of this
agreement, waiver and release.
I have read this agreement, waiver and release of liability, and agree to and accept its terms:
Last Name, First Name of Participant
Signature of Participant
Date Signed
Signature of Parent or
Legal Guardian
Date Signed
If Participant is under 18 years of age:
Last Name, First Name of Parent or
Legal Guardian
111 Milwaukee St
Sparta, WI 54656
[email protected]
(800) 354-2453
www.willtoben.com
Page 6 of 6
Total Amount Due: $_____________
Today’s Date: _____/_____/_____
Please mail all pages of this registration form and the signed event Agreement, Waiver & Release of Liability to the
following address with a check, money order or credit card (see below) payable to “Sparta Chamber of Commerce.”
Sparta Area Chamber of Commerce
111 Milwaukee St
Sparta, WI 54656
Although it is not required, we would appreciate it if you could also give us a call (800-354-2453) or email
([email protected]) us so we know to expect your completed paper registration and payment in the mail.
Please keep a copy of your registration forms for your records. It will be your responsibility to inform us of any
changes in registration information after your initial registration. We will make all reasonable attempts to
accommodate your request but cannot guarantee we will be able to do so. This also strongly depends on when you
place your request.
You will receive a confirmation phone call or e-mail and additional, more specific tour information later. We may also
contact you for additional information or specific volunteer opportunities, particularly if you will park your car in one
of the stopping towns or you indicated that you will have a non-riding friend or family member joining you during the
tour. Unless specifically requested, you will not receive a confirmation package or any printed materials in the mail. All
registration items (cue sheets, t-shirts, etc.) will be distributed on site during the tour. If you have any questions at all
regarding your registration, please feel free to contact us at any time.
If (and only if) you indicated that you will be riding with your own personal GPS, we will send you a separate e-mail
that contains a specific link to download the GPS route dataset files to upload into it. If we do not have much
experience with your specific GPS unit we may also contact you to see how well our route dataset files work with it.
Shortly after registration closes we will announce whether we will either paint road markings and put up orange flags
over the route or provide an individual GPS unit to all participants who will not be riding with one.
Please continue to check for updates on willtoben.com for the most current tour information.
Thank you for your purchase, we look forward to seeing you on the tour!
Sincerely,
Tim Hyma
Executive Director
111 Milwaukee St
Sparta, WI 54656
[email protected]
(800) 354-2453
www.willtoben.com