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Stephenville Firecracker 100

Ride Application

Please submit the form below and then click on the correct PayPal button on the next page to complete your Ride Application.

Please complete and submit a separate form for each member of the family.

Release (Please read carefully, and check "yes".)

In consideration of the acceptance of this entry, I, the person listed on the form, assume full and complete responsibility for any injury or accident which may occur to me during the Firecracker 100 or while I am on the premises of the event and I hereby release and hold harmless the sponsors, promoters, and all other persons and entities associated with such an event, or otherwise. I acknowledge that I am familiar with the dangers of participating in such an event, including by way of example and not limitation, the following: the dangers of collision with pedestrians, vehicles, other riders and fixed or moving objects; the dangers arising from surface hazards and weather conditions; and the possibility of serious physical and/or mental trauma or injury associated with athletic cycling events. I further agree that if I choose to participate in this event and not wear an approved cycling helmet I can be subject to serious head injury and assume all liability and responsibility from injuries arising from failure to do so. I have no physical or medical condition which would endanger myself or others if I participate in this event.

For additional information, call 254-965-5313 or 800-658-6490 or e-mail. If you prefer, you can also print the form and mail it to: Firecracker 100, Box 281, Stephenville, TX 76401.

Helmets " REQUIRED".
All red fields must be filled out or your form submission cannot be processed.

*IMPORTANT* In order to receive the early registration discount, we must receive your payment no later than June 25th.. Please make checks payable to: Firecracker 100

Mail to:

Firecracker 100
Box 281
Stephenville, TX 76401