CLASSIC BACKROAD BIKE RIDE
SATURDAY, SEPTEMBER 1, 2012
The theme this year will be … “Hope you have the time of your life.”
Again would like to thank all who have supported us in the past and for those
who will continue to support in the future for our cause.
Without you we would not be able to fund some of our projects that we do.
Please support us by registering and encourage all in the group that you ride with to register.
Again this is a plea to you to register if you are going to ride help out a great cause.
REGISTRATION WILL BE FROM 8:30 – 10:00 AM
RIDE STARTS @ 10:30 AM @ NEOLA’S BLUE MOON AND ENDS @ PAULEY’S PUB
A 22-MILE RIDE ON IOWA’S HWY 191
Join us back in Panama with a Street Dance. Two well known bands will be playing.
For more information on the bands please contact Pauley’s Pub in Panama.
FOR MORE INFO CALL: UPTOWN LOOKS (712) 489-2546 or leave message at (712) 489-2012.
email questionsto:
REGISTRATION FORM
(Each Rider must sign the Release on the back)
If you make copies make sure to copy the Release of Liability on the back of the form also!
MAIL REGISTRATION & MAKE CHECKS PAYABLE TO: CLASSIC BACKROAD BIKE RIDE, PO BOX 134, PANAMA IA 51562
RIDER (1) ______RIDER (2)______
ADDRESS______ADDRESS______
CITY, ST, ZIP______CITY, ST, ZIP______
PHONE______PHONE______
EMAIL______EMAIL______
The information collected will only be used for next years registration mailings. Will not be given or sold to anyone else.
ENTRY FEES
Rider (1) Rider (2)
______$10.00 RIDE ONLY______$15.00 T-SHIRT ONLY
or
______$20.00 RIDE w/T-SHIRT or TANK
______$3.00 extra for 2XL or 3XL
______$4.00 If Postmarked after Aug 9th (applies only on shirt orders – If just riding cost will remain at $10
______TOTAL AMOUNT DUE
/
______$10.00 RIDE ONLY
______$15.00 T-SHIRT ONLY
or
______$20.00 RIDE w/T-SHIRT or TANK
______$3.00 extra for 2XL or 3XL
______$4.00 If Postmarked after Aug 9th (applies only on shirt orders – If just riding cost will remain at $10
______TOTAL AMOUNT DUE
Rider (1) Rider (2)
PLEASE READ CAREFULLY
RELEASE OF LIABILITY
This must be signed by each rider!!
YOU MUST BE 18 YEARS OF AGE OR OLDER
I, ______and ______(PLEASE PRINT LEGIBLY) being of legal age, am participating in the Classic Backroad Bike Ride. I agree to release and hold harmless the Panama Young Mothers and Others, its officers, directors, employees, agents and assigns from any and all claimed property damage, personal injury, or any claim or damage related to the use and riding of a bicycle in this ride or other use and activity associated with the bike ride or anything else arising from my participation in this event.
This release covers all injuries and damages whether known or unknown, which may appear hereafter or develop from the events above referred to.
This release is made voluntarily and without any representation made by the Panama Young Mothers and Others & Panama Community Club, its officers, directors, employees, agents and assigns.
______
Rider (1)Rider (2)
______
Date Date