**Entry Form**

Name____________________________________________________________________________________

Address_________________________________________City___________________State_______Zip______

I plan to ride (circle one) 20 Miles /40 miles / 65 miles Bicycle helmets are required for each rider.

WAIVER: In signing this release, I acknowledge that I understand its intent, and I for myself, my heirs, executors, administrators, and representatives, do hereby agree and absolve and hold harmless The Winnsboro Pilot Club, Pilot Intl., City of Winnsboro, Counties of Franklin, Wood, and Hopkins, corporate sponsors, and any other parties connected with this event in any way together with their respective successor and assigns (The Sponsors), singly and collectively, from and against any blame and liability for any injury, harm, loss, inconvenience, or any other damage or kind whatsoever, which may result from or be connected in any way to my participation in the Winnsboro Tour de' Trails Bike Rally. In addition to the absolute and unqualified release from all liability, I hereby represent that I am physically capable of participating in this event, that my bicycle and any other equipment I may use in the event are in working condition, that I will observe all applicable traffic and event rules and that I will wear a helmet and generally conduct myself in a safe and prudent manner while participating in the event and I hereby absolve and hold harmless the Sponsors from any damage I may sustain because of any breach of these representations. I hereby consent to and permit emergency treatment in the event of injury or illness while participating in the event. I also hereby give permission to the Winnsboro Pilot Club to use photographs, videotapes, motion pictures, recordings, or any other record compiled during the event in any promotional materials, publications or on the internet. Notice: Waivers/Releases of riders under the age of 18 must be signed by a legal parent or guardian and NOTORIZED! An adult 21 or older must accompany the rider. I certify that I have read this waiver and release and understand its significance.

Print name:______________________________________________________

Signature____________________________________________________Date_________________

Signature (parent or guardian)_____________________________________Date________________

Name of accompanying Parent or Guardian_______________________________________________

Email address:________________________________________________________

Phone number ________________________________________________________