One rider per application/release. Please submit an additional registration for each rider.

First Name					Last Name
Address
City					State			Zip
Home Phone				E-mail
Age			Gender:      Male Female

Emergency Contact Information
First Name		Last Name
Phone #
Name of non-rider accompanying you (in case of emergency)
First Name		Last Name
I plan on riding (mileage approximate):
12 miles      25 miles      38 miles      62 miles      100 miles
How did you learn about this event?
Sponsorships
I would like to donate at the following level :
Platinum ($1,000) - 10 free registrations and 10 free t-shirts Gold ($500) - 5 free registrations and 5 free t-shirts Silver ($250) - 3 free registrations and 3 free t-shirts Bronze ($100) - 1 free registration and 1 free t-shirt Please indicate the quantity of each size t-shirt based on the sponsorship level selected above: Small          Medium          Large           XL          2XL          3XL
Free registration
I plan on having a minimum of $50 in pledges/donations. (Includes 1 free t-shirt, indicate size below) Small       Medium       Large       XL       2XL       3XL (I agree to pay for my registration if the amount of pledges turned in by the day of the ride is not $50 or more.)     I am a rider 12 years or under, accompanied by an adult. (T-shirt for child is extra - see below.)
Paid Registration			Enter Amount Due
	$20 if submitted on or before 6/02/08		$
	$25 if submitted after 6/02/08		$
T-shirts for sale
Size Price   Quantity   Total Adult Small @ $8.00 X   =    $        Adult Medium @ $8.00 X   =    $        Adult Large @ $8.00 X   =    $        Adult XL @ $13.00 X   =    $        Adult 2XL @ $13.00 X   =    $        Adult 3XL @ $13.00 X   =    $        Child Small @ $8.00 X   =    $        Child Medium @ $8.00 X   =    $        Child Large @ $8.00 X =    $
Total Due for T-shirts			$
Enter Sponsorship amount from above			$
Total Due (including registration, t-shirts and sponsorships)			$
Enter total due above. Submit the form using the Submit button below to proceed to the confirmation page and secure credit card payment site of the Visiting Nurse Association Foundation. By submitting the registration form, I confirm that I have read and accept the Consent and Liability Release below.

Consent and Liability Release - Please read carefully

Release of Organizer and Sponsors

In submitting the registration form above for myself or named participant (if her or she is under 18 years of age), I accept and agree to the following statements:

1.  I understand that bicycle riding is a potentially hazardous activity, and I voluntarily participate in it of my own free will. In choosing to attend this event, I agree to assume all risks before, during and after this event.

2. I acknowledge that I am in sound medical condition capable of participating in this ride without risk to myself or others, and that I have no known medical condition that would endanger me or cause me to endanger others.

3. I agree that I will be solely responsible for the condition of my bike and related equipment.

4. I agree to abide by the rules of the ride.

5. I consent to the use of my name, photograph or likeness, voice and written responses in promotions and advertising materials.

6. Understanding that risks exist, I HEREBY RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE AND AGREE TO HOLD HARMLESS THE ORGANIZERS, SPONSORS, COMMUNITIES, ORGANIZATIONS, MEMBERS, VOLUNTEERS AND SUPPORT PERSONNEL WHETHER INDIVIDUALS OR ORGANIZATIONS, and all successors SINGLY OR COLLECTIVELY of all blame for any injury, misadventure, harm, loss or inconvenience suffered directly or indirectly as a result of taking part in this ride or any of the activities associated with the event.

7. This waiver and release of all claims, demands, actions and liability shall include, without limitation, any injury, damage or loss to my person or property which may be caused by any act or failure to act by releasees, even if said injury, damage or loss results from the negligence of any or all of the above indemnified releasees or is sustained by me before, during or after this ride.

8. I agree to indemnify and hold harmless releasees for all lawsuits, losses, damages, claims and expenses, including attorney's fees and costs arising from relating in any respect to my participation in this ride or for my breach of this agreement. This provision will apply regardless of whether or not the lawsuit, losses, damages, claims, expenses, attorney's fees and/or costs arise out of the negligence of any of the releasees.

9. If I am a minor, my parent or guardian is also signing on my behalf, and we both agree to be bound by the terms of this agreement.

10. The laws of the State of Indiana will govern any disputes or other matters relating to this Consent and Liability Release. THIS AGREEMENT MAY NOT BE MODIFIED ORALLY AND MAY NOT BE WAIVED IN ANY RESPECT. I HAVE READ THIS AGREEMENT, WAIVER AND RELEASE AND AGREE TO ACCEPT ITS TERMS, EVIDENCED BY MY ONLINE REGISTRATION.