Florida Freewheelers, Inc., Orlando, 2005 Fall Brevet Series – Registration Form

Name: ______________________________________________________________RUSA #_________

Address: ____________________________________________________________________________

City: ____________________________________ State: _______ ZIP: ___________________________

Phone: __________________________________ Cell Phone: _________________________________

E-mail: ______________________________________________________________________________

Emergency Contact:________________________ Phone: _______________________Cell___________

$10 late fee does apply for registration within less than 24 hours prior to the start                ____________
Event Checks payable to Michael E. Grussemeyer.          Total Amount enclosed for events  ___________

Join the Freewheelers club, $25.00 (individual or Family). Receive a $5.00 DISCOUNT per event. Click here for a membership application form. Return filled out with ride registration form, waiver signed, and a separate check payable to: Florida Freewheelers, Inc.

Send all checks to: Michael E. Grussemeyer, RBA, 5363 Del Monte Court, Cape Coral, Fl. 33904 Additional Information: http://www.bike4one.com/brevets/ - RBACentralFlorida@bike4one.com

FLORIDA FREEWHEELERS, INC. / RANDONNEURS USA EVENT WAIVER

I understand that The Florida Freewheelers, Inc. and Randonneurs USA are not an insurer of my personal safety or liability during any associated activities of any and all events.

I hereby release and forever discharge and hold harmless The Florida Freewheelers, Inc. and Randonneurs USA, their members, agents, servants, representatives, successors, sponsors, volunteers and assignees from all liability (personal and property) arising out of, or connected in any way with my participation in this event (or my minor child's participation in this event).

I also agree to fully comply with all applicable laws and traffic regulations; to conduct my activities in a safe and prudent manner; and to wear an approved bicycle helmet and any other safety equipment required by the event.  I also agree not to use headphones while riding.

__________       ___________________________________                       ___________________________________

     Date                                                Type/Print Name                                                                    Signature

__________       ___________________________________

     Date         Parent’s or Guardian’s Signature/Under 18 Years Old