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First Name:*
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Last Name:*
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Street Address:*
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City:*
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State:*
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Zip Code:*
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Phone Number:*
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Emergency Phone Number:*
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E-Mail:
(Please see note (1) below)
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Type of Entry:*
(Please see note (2) below)
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Family Name:
(Please see note (3) below)
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Birthdate:*
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Gender:*
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T-Shirt Size:
(Please see note (4) below)
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Comments:
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(1) Please enter an e-mail address if possible. If you specify an e-mail address,
a copy of your entry form will be sent to the e-mail address you provide.
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(2) Fee payment of $25 covers families consisting of two or more persons.
A registration form must be submitted for each member of the family and
the same family name must be entered in the Family Name box below for each family member.
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(3) Please enter the last name of your family if you are submitting a family entry.
Please enter the same family name in the Family Name box for each family member.
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(4) Individual adult or child fee payment includes one official Lago Vista 4th of July t-shirt.
Family fee payment includes two official Lago Vista 4th of July t-shirts,
with additional t-shirts available at a discounted price of $5 for family members.
If you are submitting an individual adult or child entry,
please indicate your t-shirt size so we can have your shirt ready for you.
If you are submitting a family entry,
please indicate a t-shirt size on the entries that you submit for two or more
of your family members, depending on how many additional discounted t-shirts
you intend to purchase, so we can have your shirts ready for you.
Please leave the t-shirt size select box untouched on entries
for family members for whom you do not intend to purchase additional discounted t-shirts.
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Release from Liability and Indemnification
We wish to participate in the Hills and Spokes Family Bicycle Rally.
We, individual(s) or organization, Indemnify and Hold Harmless the Lago Vista
4th of July Council, its Volunteers, the City of Lago Vista from any and all
claims, suits, losses, damages, expenses on account of the Hills and Spokes Family Bicycle Rally.
Further, the noted individual(s) or organization will defend
the Lago Vista 4th of July and the City of Lago Vista, and its agents from all
claims or bodily injury or property damage arising from their participation in
the Hills and Spokes Family Bicycle Rally. We understand that we are responsible for
our own safely and actions. By checking the box below, I, the individual named
in the First Name and Last Name boxes above, signify that I
have read this Agreement and understand and agree to all its terms.
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I have read the above Release from Liability and Indemnification
agreement and understand and agree to all its terms.
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I agree
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