Name:________________________________Address:____________________________________

City:_____________________State:______Zip:___________e-mail_____________________

Phone (Day)_______:_________(Evening)____________________Club,if any:__________________

Please circle the costs or the word “included” in the block for any event in which you will participate. You may change or add rides; however, we ask that you mark the one(s) that you will most likely take so that the rest stops can be stocked
accordingly.

SATURDAY, SEPT 26
Patrick Henry Century (100 mi.) [Red Hill and the Battlefield Park]	(included)
Red Hill Metric Century (64 mi.) [Red Hill]	(included)
Railroad Route  (28 mi) [Includes Treasure Hunt for souvenir pieces]	(included)
SUNDAY, SEPT 27
Statesmen Ride  (29 mi)	(included)
Queen Charlotte Ride (14 mi)	(included)
Camping/camper space, no hook-ups; showers at Middle School ($5.00 for one or both nights to defray costs.) Friday night__ Saturday night__	$5.00
Circle all meals you plan to eat. Circle here for Vegetarian menu.	Yes, vegetarian menu please.
SATURDAY Breakfast	$7.50
SATURDAY Box Lunch	(included)
SATURDAY Supper/Dinner	(included)
SUNDAY Breakfast	$7.50
FULL REGISTRATION (includes walking tours, Saturday lunch & supper, entertainment, all rest stops, ride support, T-shirt, ride souvenir, Free admission to Red Hill Shrine.) Children under 6 free	$57.50
NON-RIDERs and MINORS 6 - 16 REGISTRATION (includes walking tours, Saturday lunch & supper, entertainment, T-shirt, ride souvenir.  Free admission to  Red Hill Shrine.)	$32.50
LATE REGISTRATION FEE (after Sep 16)	$7.00
GRAND TOTAL (checks payable to Museum of Charlotte County)
Call for information: 434-248-6407

T-shirt Size:[__sm] [__med] [___lrg] [___X-lrg] [___XX-lrg]
(If size is not marked, large will be given. Available sizes may be limited for late registrant)

Mail payment and registration to Museum of Charlotte County, P O Box 323, Charlotte Court House, VA 23923. $15.00 refund charge for all refunds before Sep 16. There will be no refunds after September 16. No refunds due to bad weather.

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT (‘agreement’):
IN CONSIDERATION of being permitted to participate in any way in Charlotte Spin Club ("Club") sponsored Bicycling Activities, including the 2009 Ride in the Heartland ("Activity") I, for myself, my personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of Bicycling Activities and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further acknowledge that the Activity will be conducted over public roads and facilities open to the public during the Activity and upon which the hazards of traveling are to be expected. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.
2. FULLY UNDERSTAND that: (a) BICYCLING ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the conditions in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the Club, the League of American Bicyclists, its respective administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the Activity takes place, (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim.

I AM 18 YEARS OF AGE OR OLDER, HAVE READ AND UNDERSTAND THE TERMS OF THIS AGREEMENT, UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, HAVE SIGNED IT VOLUNTARILY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. I AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE,
NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

____________________________________ ______________
Signature of Entrant ............................................... Date

____________________________________ ______________
Signature of Parent or Guardian ..............................Date
(if entrant is under age 18)