Life Without Limits Ride 2 D. C. 2016

Name:______________________________________

T-Shirt size(circle one)

    XS     S     M     L     XL     XXL     XXXL

Address:___________________________________________

City:_______________________________________________

State:_______________________________________________

Zip:_________________________________________________

Email:_______________________________________________

Passenger Name:______________________________________

Participant Signature:_______________________________

Passenger Signature:_________________________________

Fee Paid: _______ X $70 = ___________________________

Passenger T-Shirt size(circle one)

    XS     S     M     L     XL     XXL     XXXL

Suggested Donations:

1 Segment: $70     2 Segments: $105
3 Segments: $140     4 Segments: $175
Full Ride: $210

Rider/Passenger Release:

I am entering this event ay my own risk.  In signing this release for myself (and named passenger, if applicable), I understand this release and agree to absolve all sponsors, organizers, and associated entities of all liability for any injury, harm or loss or inconvenience suffered as a result of taking part in the Ride2DC.  I agree to obey all State Traffic Laws.  I also give permission for the free use of my name and or picture in any telecast, broadcast or any other account of this event.

Rider Signature:_________________________________

Date:_________________________________

Passenger Signature:_________________________________

Date:_________________________________

Retrurn form with your check to:

    Life Without Limits Ride 2 D.C.

   United Cerebral Palsy of West Central Wisconsin
   206 Water Street
   Eau Claire, Wisconsin 54703