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| Tour d' Cotton Bicycle Ride Saturday, October 6, 2012 |
| Name (please Last First MI Address:____________________________________________ City:____________________________State:________ZIP___________ 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. |
| REGISTRATION FORM 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_________ |
| Childress Palace Theater |
| E-mail jude747@att.net |
