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Today is Saturday, November 21, 2009.

MAYO LAKE CYCLYSM REGISTRATION

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2009 Mayo Lake Cyclysm Registration Form

25K 50K 75 Bicycle Tour

Saturday October 10, 2009

Mayo Park Roxboro, NC

All cyclists must sign waiver form prior to participation in this event.

* Information is required.

Contact Information

* First Name:
* Last Name:
Business Name:
Email:
* Daytime Phone:	() –
Fax:	() –
* Address:
* City:
* State:
* ZIP:

* Date of Birth (Must Be age 11 or older)

Home Telephone

Male

Female

Team Name

Team Captain's Name

* T Shirt Size

Small

Medium

Large

Extra Large

XXL

* Route

25K 15.5 Miles

50K 31 Miles

75K 46.5 Miles

Fund Raising Goal - No Minimum is Required

* Emergency Contact Information: Name

* Relationship

* Telephone Number for Emergency Contact

* Registration Fee - Includes T Shirt & Lunch for Cyclists

* Raffle Tickets $500 Gift Certificate Dicks Sporting Good Tickets are $1 each or Book of 6 for $5 Raffle tickets may be purchased at the event.

* Additional Lunch for Family or Friends $6 Each

* Total (Make Checks Payable to Kiwanis Club of Person County)

Credit Card Information

Credit Card Number

Expiration Date Month

Expiration Date Year

CVS Number (3 or 4 Digit Number on Back of Credit Card)

Total Amount Charged to Credit Card

Check here to have email confirmation of this request sent.

* Information is required.

Mail Completed Form To:

Kiwanis Club of Person County

P. O. Box 1660

Roxboro, NC 27573

Fax Form To: (336) 599-3774

Contact Information:

James C. Overton

Telephone: (336) 599-3116 Work

Telephone: (336) 322-3000 Home

E-mail: joverton@esinc.net

Visit our webistes at:

http://mayo.personcounty.net or www.pcunitedway.org

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