Tour d' Cotton Bicycle Ride
Saturday, October 6, 2012
Name (please                Last                                 First                              MI


Phones:______________  ______________ E-Mail_________________
Home                             Cell

Note:  Credit Cards Cannot Be Accepted This Year.  Cash,
personal checks,
PayPal & cashiers checks will be accepted.

Please provide the following medical info:  Age____Medical History
(heart disease, diabetes, seizures, recent surgeries, any special
needs, etc.__________________________________________________
Allergies: (food, meds, any other)______________________________
Emergency Contact(s)________________________________________
Emergency Phone Nos._______________________________________
________________________________________________  __________
(Signature of rider or parent of minor)                                 (Date)

Entry fee is $30 per person.  Family Rate allows $5 discount for all members of the
same household after the first member pays regular price.  
Children 13 & under must
be accompanied by an adult
on all routes of Tour d' Cotton.  Waiver/Release forms must
be signed the DAY of RIDE by each adult cyclist and a parent of a minor.
Mail to:  Tour d' Cotton,   Attn: Judy Johnson
P.O. Box 182             Childress, TX 79201
Tour d' Cotton Distances

60 Miles______                                   Please Indicate Ride Distance                            8 miles______
30 miles______                                     & T-Shirt Sizes                                              Shirt Size_________        
Palace Theater