Entry Form

Please print this form

Yes, I want to participate in the 2001 Paris to Ancaster / Harrisburg to Ancaster Epic ride. I am prepared to accept the challenge and have read, understood and signed to release form. Mountain bikes, hybrids or cyclocross bikes are recommended. (includes t shirt for first 300 only)

___ Paris to Ancaster 60km $40

___ Harrisburg to Ancaster 30km $35

Name ______________________________________Age_________Sex________

Club ________________________

Address___________________________________________________________

City__________________________ Province/State______________

Postal Code_________

Telephone_______________________

Email ___________________________

___ No, I don't need a ride to the start. I have made arrangements to be dropped off at the start and picked up at the finish.

___Yes I will need a ride to the start line in Paris I will meet the bus at The Firestone Community Centre on Jerseyville Rd at 8:30 sharp on April 22. I have enclosed $5 to cover the cost . Bike transport is included.

___ Yes I will need a ride to the start line in Harrisburg I will meet the bus at The Firestone Community Centre on Jerseyville Rd at 8:30 sharp on April 22. I have enclosed $5 to cover the cost . Bike transport is included.

Total $ enclosed __________

Please make cheques payable to:The Special Event Company.
Mail to: 1064 Westhaven Dr.
Burlington, Ontario
L7P 5B5


For more information email tjfarrar@earthlink.net or call 905-331-3173

Waiver

In consideration of the acceptance of this entry, I intend to be legally responsible for myself, my heirs, administrators, executors and do herby discharge and release the organizing committee of the Paris to Ancaster and Harrisburg to Ancaster race and tour , the Special Events Company, The Ontario Cycling Association, any and / or all sponsors and their representatives, assigns and successors from any and all liability arising from injuries, illness, and damages that I may suffer as a result of my participation in this event or transportation to and from the event venues. I further attest that a medical doctor has verified my physical condition in the past twelve months and I consent to medical treatment. I also release my permission for the free use of my name and / or picture in any broadcast, telecast, webcast or other account of this event. On public highway sections of this race and tour I agree to abide by the Ontario Highway Traffic Act and to follow the instructions of the race marshals and police officers.

Signature of participant:_____________________________________________


Signature of Parent or Guardian:_______________________________________
(if participant is under 18 years of age)


Date:_________________