Harmon Hundred Entry Form

Make checks payable to: Wheeling Wheelmen
Mail to: Wheeling Wheelmen, P. O. Box 7304, Buffalo Grove, IL 60089-7304
A separate entry form is required for each rider.
No Pre-Registration accepted after 9/04, please register at the Harmon. Your cancelled check is your receipt.
PLEASE PRINT

Last Name:	First Name:
Street Address:
City:	State:	ZIP:
E-Mail:	Home Phone:
Emergency Contact Name: Is this person also on the ride? YES NO	Emergency Phone Number:

Liability Waiver
In signing this waiver for myself, or as a parent or legal guardian for the entrant named above, I hereby release from responsibility and hold harmless from any claim, foreseen or unforeseen by me or my family, estate, heirs or assigns, the Wheeling Wheelmen, Inc. ("Wheeling Wheelmen"), and it's agents, employees, officers, volunteers, other participants, any sponsors, advertisers and owners or lessors of the premises on which the Harmon Hundred takes place for any and all claims, damages, demands, injuries and losses whatsoever, arising from my transportation to, participation in, and/or presence at the Harmon Hundred, and do so entirely of my own initiative. I understand that riding a bicycle on a public street or road can be a risky and dangerous activity and may result in serious bodily injury, including permanent disability, paralysis and death (collectively "risks"). I fully accept and assume all such risks and all responsibility for all costs, damages and losses I incur as result of my participation in the Harmon Hundred. I agree to obey all traffic laws and operate my bicycle in a safe manner. I certify that I have read this waiver, fully understand it's terms, understand that I have given up substantial rights by signing it and have signed it of my own free will and accord. If the entrant is a minor, I, the minor's parent or legal guardian, understand the nature of bicycling activities and the minor's experience and capabilities and believe the minor to be qualified to participate in the Harmon Hundred. I also authorize emergency medical treatment if I or the above minor is injured.

* Signature:	** Age if under 18:
Printed name of Parent/Guardian:	Date:

* Rider under 18 requires signature of parent or guardian.
** Rider 12 years or under must be accompanied by an adult throughout the ride.

	Rider Fee	T-Shirt	AMOUNT	TOTAL
On or before August 1, 2012	$10.00	$10.00	$_________	$________
On or before September 4, 2012	$20.00	$12.50	$_________
After September 4 and day of ride	$25.00	$15.00	$_________