Southern Tandem Rally Registration Form
Please print, fill it out in full, and mail to the address at the bottom of the form.
Participant Information
Team Name:
 _____________________________________________________
Captain:
  ___________________________
Stoker:
 ___________
Address:
  		  ____________________________________________________   
 ____________________________________________________
 ____________________________________________________
Phone
 ____________________________
E-Mail:
 ___________
Emergency Contact
  ____________________________________________________   
 ____________________________________________________
Event Release:
 

I understand I am registering to participate in a bicycle event to be conducted on the public roadways of Tennessee and Virginia. I understand bicycling is potentially a dangerous activity. I understand I might be severely injured or killed while riding a bicycle in this event. I hereby accept the risk of serious bodily harm or death and do, by my signature below, release and hold harmless all persons or entities associated in any way with the production of the 2005 Southern Tandem Rally. Where more than one person signs this form, it is understood each person accepts the risks of riding a bicycle on the roadway, release and hold harmless, all persons or entities associated in any way with the production of the 2005 Southern Tandem Rally. All riders agree to wear a helmet that satisfies the requirements of A.N.S.I. or Snell to protect them from serious head injury and all riders agree to obey all Tennessee and Virginia laws during the ride.


All riders in the rally must sign. Parents or legal guardians are required to sign for minor children participating in the ride.

________________________________
________________________________
Name / Date
Name/Date
  
________________________________
   ________________________________
Name/Date
Name/Date
  
________________________________
   ________________________________
Name/Date 
Name/Date 
 

Expected Date and Time of Arrival in Kingsport: __________________________
 
We plan to participate in the following rides: (preferences are not binding but give the committee an idea of the level of participation for planning)
Please check your preference below:
Friday Afternoon:     
Saturday:
46 Miles
         
59 Miles
  
80 Miles
  
Sunday: 
Out and back (maximum of 45 miles)
 
   
Ride around Bays Mountain 60 miles)
 

Jersey/Shirt Size (circle desired size) 
Captain
S
M
L
XL
XXL
  
Stoker
S
M
L
XL
XXL
Additional Jersey/Shirt
S
M
L
XL
XXL
Additional Jersey/Shirt
S
M
L
XL
XXL
 
Registration Fees (Before August 31, 2005)
Team Registration:   $190.00  
  Additional Riders $90.00 each    
 
Number of additional Riders X $90.00 =
    
  Non-riding Guests $70.00 each     
  
Number of non-riding guest X $70.00 =
    
   
Total:
    
Registration Fees (After August 31, 2005)
Team Registration:   $205.00  
  Additional Riders $ 100.00 each    
 
Number of additional Riders X $ 100.00 =
    
  Non-riding Guests $85.00 each     
 
Number of non-riding guest X $85.00 =
    
   
Total:
    
Make Checks Payable to:
     Make checks Payable to: Southern Tandem Rally
Mail to:    
   

Ms. Wanda Thorpe
Kingsport Convention And Visitors Bureau
P.O. Box 1403
Kingsport, TN 37662