Annual Tour de Dutchess Bicycle Fest

September 25, 2011  Lakeside Park, Pawling, NY

Helmets Required!                                                      Don’t Forget Your Water Bottle!

Check or Money Order  payable to TSA of GNYS in the amount of $20.00. Please mail by September 14, 2011 to: Tour de Dutchess c/o Lieb Chiropractic,  3194 Route 22, Patterson, NY 12563.

Note that a separate form must be completed for each individual participating.  This form may be duplicated.  (Please write clearly)

Name:____________________________Email:___________________________ 

Address:__________________________ City:____________________________           

State:__________Zip:_______________Phone Number:____________________

Emergency Contact___________________Phone Number:____________________

Please Circle T-shirt size:       S           M           L           XL

Please Circle Intended Ride Route:    13        27        50  (miles)
Waiver of Liability:
I know that cycling is a potentially hazardous activity. I will not enter the Tour de Dutchess Bicycle Fest unless I am medically able and properly trained. I agree to abide any decision of the route officials relative to my ability to safely complete the event. I assume all risks associated with participation in this event including, but not limited to, fall, contact with other participants, the effects of weather, including high temperatures, and/or precipitation, traffic and the conditions of the road, all such risks being known and appreciated by me. I authorize the Tour de Dutchess to provide medical attention for me at my expense should I appear in need. Having read this waiver and knowing these facts, and in consideration of the acceptance of my application, I for myself and anyone entitled to act on my behalf, waive and release all organizers and volunteers, The States of New York and Connecticut, Counties in NY:  Dutchess, Putnam; Counties in CT: Fairfield, Litchfield; Town and Village of Pawling, all towns and landowners along cycling routes of this event, all sponsors, their representatives and successors, from all claims or liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence on the part of persons named in this waiver. I grant permission to all of the foregoing to use any photographs, motion pictures, recordings or any other record of this event for any legitimate purpose.                                                                                                                                                                                                                      

I, the participant, have read and agree to the waiver of liability on this  application. I acknowledge that entry fees are non-refundable
and non-transferable for any reason.
                                                               
Signature of Participant________________________________________                                                          No._________