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 20
Patrick Henry Century (100 mi.) [Red Hill and the Battlefield Park]	(included)
Red Hill Metric Century (64 mi.) [Red Hill]	(included)
John Randolph Tour (33 mi) [Staunton River Battlefield State Park ]	(included)
SUNDAY, SEPT 21
Statesmen Ride  (29 mi) NEW ROUTE FOR 2007	(included)
Queen Charlotte Ride (14 mi) NEW ROUTE FOR 2007	(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, Free admission to Mulberry Hill & 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, Free admission to Mulberry Hill & Red Hill Shrine.)	$32.50
LATE REGISTRATION FEE (after Sep 10)	$7.00
GRAND TOTAL (checks payable to Museum of Charlotte County)
Local novice riders who choose the "6-mile Flatland Ride," lunch only, no T-shirt, do not need to pre-register. 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 10. There will be no refunds after September 10. 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 the 2006 Ride in the Heartland (‘activity’) on September 19-21, 2008, an event sponsored by the Museum of Charlotte County and the Charlotte Spin Club, I, for myself, my personal representatives, assigns, heirs, and next of kin: I 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 hat the Activity will be conducted over public roads and facilities open to the public during the Activity and upon which hazards of traveling are to be expected. 1. 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. I FULLY UNDERSTAND that all participants in the activity are required to wear bicycle helmets, and I agree to wear a bicycle helmet while riding a bicycle as part of any event connected with the Activity. 3. I FULLY UNDERSTAND that (a) BICYCLING ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH (‘risks’); (b) The risks and dangers may be caused by my own actions, or inactions, the actions or inactions of other participants in the Activity, the conditions under which the Activity takes place, or THE NEGLIGENCE OF THE ‘RELEASEES’ NAMED BELOW; © 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 or that of a minor, in the Activity. 4. I HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE The Museum or Charlotte County or the Charlotte Spin Club, heir representative administrators, directors, agents, officers, members, volunteers, and employees, other participants, and 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 HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE SIGNED IT FREELY AND WITHOUT INDUCEMENT OR ASSURANCE OF ANY NATURE, INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW, AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THAT 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)