2007 Benge's Revenge

Registration

Name___________________________________________________________________________________

Address_________________________________________________________________________________

City, State & Zip________________________________________________Phone______________________

Emergency Contact Name & Phone #__________________________________________________________

Male_____     Female_____     Age_______     T-Shirt Size:  M_____     L_____     XL_____     2XL_____

I Plan to Ride:  3/4 Century_______     1/4 Century_______ 

Waiver

For and in further consideration of the right to participate in “Benge’s Revenge,” the undersigned does hereby release, absolve, and hold harmless Norton Kiwanis Club, the City of Norton, and any other sponsors of this event, their heirs, successors, assigns, employees, agents, and personnel from any and all actions, causes of action, or liability as a result of taking part in “Benge’s Revenge.”  I further covenant, warrant, and agree that I am entering into this event of my own free will and am voluntarily executing this release.  I understand this is not a race but a ride, and I will obey all traffic laws as issued by the state of Virginia and the Federal Government.  I also agree to yield to normal traffic flow while riding the designated route.  I understand that wearing a helmet is required for participation in this event.  I further understand and agree that the cosponsors of “Benge’s Revenge” make no warranties whatsoever and are not insurers of, nor responsible for my safety during “Benge’s Revenge” or while I travel to or from the event.  When no parent or guardian has signed this form where indicated, the entrant specifically warrants and represents that he/she is over the age of eighteen (18) years and is not suffering under any mental or physical infirmity which might adversely affect his/her judgment and/or participation in “Benge’s Revenge.”

I have read the foregoing release.  I understand the content thereof, and I do willingly execute the same this day of September 23, 2007.  I understand all information in this form and where the route of “Benge’s Revenge” is located.  I further attest that all the information I have provided on this form is true.

Signature of Participant:___________________________________________________________________________

 I am the parent/guardian for the above entrant who is under the age of eighteen (18).  By executing this document, I do consent to the entrant’s participation in 2007 Benge’s Revenge.  I do consent to the terms of this release, and I do further agree to be fully bound by the terms of this release, both individually and as parent/guardian of the entrant.

Signature of Parent/Guardian:______________________________________________________________________