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.
