Dean's Ride 2015 registration form

Plant City Family YMCA Proudly Presents
THE THIRD ANNUAL
DEAN’S RIDE:
STRENGTH & HONOR
Proceeds will benefit the Plant City Family YMCA’s LIVESTRONG program which provides a wellness program
for cancer survivors and is free to participants. This 12 week program is designed for adults who have
recently become de-conditioned or chronically fatigued due to their treatment and/or disease.
Saturday, January, 17, 2015 at 7:45am
Start/End at HCC Plant City Campus
Start Time: 8:00am (Start & Finish at HCC, Plant City Campus)
Cost: $30 (includes a T-shirt) Must be 14 or older to ride.
Register: online at www.tampaymca.org, www.active.com,
or mail your registration form to Plant City Family YMCA
• Route support & sag stops provided
• Light Breakfast & Lunch
BIKE RIDERS MUST
WEAR HELMETS
For more information contact Reagan Thomas ([email protected])
REGISTRATION FORM
Make checks payable to Plant City Family YMCA.
Select Race o 18 Mile Bike Ride ($30)
o 38 Mile Bike Ride ($30)
o 62 Mile Bike Ride ($30)
Non-rider donation o includes T-shirt $20 or other _______________________________
T-shirt size* (Adults only,circle one) S / M / L / XL / XXL
*To guarantee t-shirt size registration deadline 12/20/14
Name (please print clearly): _____________________________________________________________________________________________________D.O.B.: _____________________________
Address: _____________________________________________________________ City: _________________________________________________ State: _________ Zip: ____________________
Age: _____ Sex (M / F): _____ Phone: _________________________________________________ Email: ________________________________________________________________________
Waiver: BIKE RIDERS MUST WEAR HELMETS. In consideration of acceptance of this entry, I for myself, my heirs, devises, executors, administrators and assignors, hereby waive,
release and discharge any and all claims against race organizers, sponsoring or conducting this event or their employees, representatives, or successors, for any and all damages
or injuries I may suffer. I hereby grant permission for the free use of my name and picture in any broadcast, brochure or account of this event.
Signature (parent signature if participant is under 18): ____________________________________________________________________________ Date: __________________________
If mailing in registration, deadline is 1/10/15. Mail this form to: Plant City Family YMCA, 1507 YMCA Pl., Plant City, FL 33563.
Registering in person at the Plant City Family YMCA and online registration will be available until 1/15/15 by noon.
**Day of registration will start at 7am – Cash/checks only