Piece Ride for Autism

6th Annual

6th ANNUAL PIECE RIDE FOR AUTISM


ALL PROCEEDS BENEFIT 

VERMONT FAMILIES AFFECTED BY AUTISM

 

 $25 per person  

(includes: t shirt, end of ride meal  and 1 prize ticket)

Event Date & Time: June 23, 2018

   Event Starting Location: Backstage Pub, Essex Jct., VT


Waiver: In consideration of my entry in the PIECE RIDE FOR AUTISM, I hereby waive, release & discharge any and all claims for damages, injury and property damage, which I or my successors may have, or which may hereafter occur to me as a result of my participation in this event. This release is intended to discharge in advance the promoters, sponsors, and all municipalities and public entities (and their respective agents and employees) from and against any and all liability arising out of or connected in any way with my participation in the event.I understand the risks involved in participating in such an event. I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned.

            PARTICIPANT NAME:     ........................................................................

              ADDRESS:            ....................................................................................

                                             ....................................................................................


              TELEPHONE:        ( ..............)     .......................... -    .............................


              E    MAIL:            ......................................................................................


              SIGNATURE OF PARTICIPANT:     ..........................................................



TO PRE REGISTER:


PLEASE PRINT AND SIGN THIS FORM


MAIL THE COMPLETED FORM 


WITH A CHECK FOR REGISTRATION FEE


OF 


$25 PER PERSON


TO:


 Piece Ride for Autism

21 Bellevue Street

Winooski, VT 05404


Web: http://pieceride.webs.com


E mail: [email protected]


Phone: (802) 238-0101