Wisport 2008 Membership Application (Print and mail.)
| Individual | Road Race Series: $25.00 | Time Trial Series: $20.00 | Both: $35.00 | ||||||||||||
| Household (Each member) | Road Race Series: $20.00 | Time Trial Series: $15.00 | Both: $30.00 | ||||||||||||
| Tandem Team (Both riders) | Road Race Series: $25.00 | Time Trial Series: $20.00 | Both: $35.00 | ||||||||||||
| Tandem Partner's Name is: | Tandem membership $15 with 2 individual road series members. | ||||||||||||||
| Are you entering as a recumbent rider? | Faired | Non-faired | |||||||||||||
| Weigh over 200 lbs? Enter the Cruiser Category $10.00 | Weigh under 140 lbs? Enter the Fly Weight Category $10.00 | ||||||||||||||
| Last Name | First Name | Date of Birth mm/dd/yy |
|
Sex | Road Race | Time Trial | |||||||||
| Mailing Address | |||||||||||||||
| City | State | Zip | |||||||||||||
| Phone Number | Email address | ||||||||||||||
| Emergency Contact | Team Name | ||||||||||||||
| Emergency Contact Phone | Would you prefer to have the results mailed? Yes No | ||||||||||||||
| Each rider sign and
date below. For riders under the age of 18, parent or legal
guardian must sign and date. IMPORTANT, Parent / guardian please print your name and the name of the minor next to your signature. |
|||||||||||||||
| By signing, below you agree to abide by the
rules and decisions of Wisport and the race directors. You further understand that Wisport, its members, sponsors, officers and directors are not responsible for, nor have they made any representations about the safety of, and/or the safe conduct of any series events or activities, and you hereby relieve them of any liability therefore. |
|||||||||||||||
| Signature | Date | ||||||||||||||
| Make check payable
to: Wisport Cycling Series. |
Mail
to: Wisport Cycling Series, 7133 Valhalla Trail Madison, WI 53719 |
Amount enclosed: $ | |||||||||||||