§ EC-LaX-EC §

Registration Form

Date ________

Name ______________________________

Address ______________________________

City _____________________

State _____________

Zip ___________

Phone ____-______________

� Tour fee (includes: luggage transport, food & drink at @ $25 ____

rest stops, map & cue sheet, sag & mechanical

support vehicle)

� Econolodge motel- Friday, August 27, 2004 @ $61.86 ____

(single or double occupancy – 2Q/NS)

� Holiday Inn Express Motel- Saturday, August 28, 2004 @ $93.88 ____

(single or double occupancy – 2Q/NS)

„ Bluebird Springs Recreational Area (camping) @ $5 ____

(Group site)($5 per person)

__________________________________________________________________________

Total $_______

Waiver: As an entrant in the Eau Claire-La Crosse-Eau Claire Cycling Tour, I know that participation in this event could potentially cause injury. I should not enter unless I am medically able and in fit condition. I accept the risks associated with participation in this event and agree to practice road safety. I understand that wearing a helmet is required. Understanding the foregoing and in consideration of accepting my entry, I hereby release and discharge the event organizers and volunteers from all claims or liabilities of any kind or nature resulting from, or arising out of, or incident to my participation in this event.

Signature required________________________________________

                (Parent or Guardian must sign if age 17 or under)

Age_______ Date_______________

Emergency contact________________________________________

Telephone_____-_________________

Make checks payable/mail to: Tom Mackaben § 2703 Parkway Dr. § Stevens Point, Wi. 54481 715-344-5118 § nebakcam@charter.net