OFFICE USE ONLY
Rider # _______________
Pledge Form Registration Form Amount Paid ___________
MAYWOOD EARTH RIDE 2009 Check # _______________
Based on donations received on or before September 19. 2009. All pledges
One Form per Rider (form may be photocopied) Cash _______________
due at check-in to qualify for prizes.
RAISE RECEIVE PLEASE PRINT
$50 Maywood Earth Ride T-shirt and Wigwam Socks Name:
$75* Free Registration (individual) Address:
$150* $20 gift certi cate from area business (variety to choose from) City/State/Zip:
$300* $30 gift certi cate from area business (variety to choose from)
Phone: ( ) Age:
Email:
$500* $50 gift certi cate from area business (variety to choose from)
Emergency Contact:
$800* $75 gift certi cate from area business (variety to choose from)
Phone: ( ) Relation:
$1000* Free Bicycle or $250 Gift Certi cate from Wolf’s Cycle
Riding with Team:
*INCLUDES . . . free registration, Maywood Earth Ride T-shirt and Wigwam Socks
I will ride: 12 mi. 25 mi. 50 mi. 70 mi. 100 mi.
Pledge premiums are subject to change and availability. (check one)
Please check with your employer for corporate sponsorship. All pledges and Entry Fees On or Before September 1:
donations must be received on September 19 to qualify for prizes. All prizes will be $30 - Individual
available for pick-up at registration. All prizes are per category and not cumulative. $25 - Association Member
$10 - Child (age 12 or under)
Thank you for supporting Maywood! Free - $75 or more in donations (per individual)
Kids in tow are free
Sponsor's Name Pledge
Entry Fees After September 1 to day of ride:
$ $35 - Individual
$30 - Association Member
$ $15 - Child (age 12 or under)
Free - $75 or more in donations (per individual)
$ Kids in tow are free Entry Fee: $
$ I am unable to ride; please accept this donation. $
$ I would like to become an Association Member. $ 20.00
Friday night camping fee (per individual) $ 5.00
$
Maywood Earth Ride T-Shirts:
$ I plan to raise $50 or more in pledges to receive a FREE Maywood Earth
Ride 2009 Long or Short - Sleeve T-shirt (select below)
$ I would like to purchase a Maywood Earth Ride 2009 T-shirt (select below)
$ (Adult T-Shirt & the Youth T-Shirt is Light Blue)
circle one:
$ Adult Long-Sleeve: S M L XL XXL $ 15.00
Adult Short-Sleeve: S M L XL XXL $ 10.00
$ Youth Short-Sleeve: S M L $ 8.00
Total Enclosed: $
$ (sorry, no credit cards)
Please mail form with your non-refundable fee (payable to "Maywood") to:
$ Maywood Earth Ride
3615 Mueller Road
$ Sheboygan, WI 53083
$ Please read this disclaimer carefully and sign below:
I, the undersigned, know that the Maywood Earth Ride is a potentially hazardous event, and attend it out of my own free will and choice.
$ The Maywood Earth Ride includes activities which may include risks such as, but not limited to, falls, interaction with other participants,
effects of weather, equipment failure, inadequate safety equipment, theft, camping, traf c and road conditions. In considerations of being
$
allowed to participate in this event, I hereby fully accept and expressly assume all risks, including personal injury and death, arising out of my
participation in the Maywood Earth Ride and related activities. It is my responsibility to dress appropriately and wear a bicycle helmet while
cycling. Although route maps, rest stops, refreshments and other assistance may be available during this event, I am solely responsible for my
$ participation in this event, and I agree to stop and request assistance if I experience any symptoms such as, but not limited to, dizziness,
excessive fatigue, shortness of breath, pain, or any other condition which would make it dif cult or unsafe for me to continue. I waive my
rights of privacy or publicity and grant permission to all of the foregoing to use any photographs, motion pictures, videotapes, recording or
$ other record of this event for any legitimate purpose. I agree, for myself, my heirs, executors, and administrators to not sue and to release,
indemnify and hold harmless the Ellwood H. May Environmental Park Association of Sheboygan County, Inc., its af liates, of cers, directors,
$ volunteers, and employees, all sponsoring businesses and organizations and their agents and employees and the City of Sheboygan from any
and all liability claims, demands, and causes of action whatsoever arising out of my participation in the event and related activities–whether it
results from negligence of any of the above or from any other cause. This release and indemni cation agreement shall be as broad and
Subtotal-contributions on this pledge form $ inclusive as is permitted by the State in which the event is conducted, any portion of it is held invalid, the balance shall continue in full force
and effect. I have read, understood and agree to the terms of this agreement.
Total-contributions from all pledge forms $ PARTICIPANT'S SIGNATURE DATE
If Participant is a minor, parent or guardian must sign below:
(Make copies of this form as needed) I am the legal guardian of participant, and hereby consent to his/her participation. I have read the foregoing release and
Maywood is supported by The Environmental Park Trust of Sheboygan County, indemni cation agreement, and hereby agree on behalf of myself and the participant to its terms.
a 501(c)(3) non-profit organization. All donor pledges are tax deductible.
Donations of $250 or more will be acknowledged with a tax receipt. Please provide GUARDIAN'S SIGNATURE DATE
name and mailing address for a business or individual pledging $250 or more.
PRINTED NAME
A tax receipt will be mailed directly to this donor.