24 Hours of DINO Entry Form 2012

ENTRY FEES per person includes on-site camping, showers, t-shirt, two meals, and more

24 Hr: before 9/1:$110               9/1-9/6: $115                 race weekend:$120

12 Hr: before 9/1:$90                 9/1-9/6: $95                   race weekend: $100

6 Hr: before 9/1:$60                  9/1-9/6: $65                   race weekend: $70

USA Cycling one-day permit: add $5 per person
  (required of all riders who are not members of USA Cycling)

ALL RIDERS MUST SIGN A LIABILITY RELEASE FORM AT THE RACE VENUE. No refunds.

DIVISION (Circle one):

24-hour 1MA, 1WM, 2MA, 2CO, 2WM, 4MA, 4WM, 4CO, 4BG, 6MA, 6WM, 6CO, 6BG, SS

12-hour 1MA, 1WM, 2MA, 2CO, 2WM, 4MA, 4WM, 4CO, 4BG

6-hour 1MA, 1WM

NUMBER OF RIDERS ON TEAM: __

Team members please enter the same team name in TEAM/SPONSOR blank below.

USA Cycling LICENSE TYPE: ANNUAL___ 1-DAY PERMIT___ ($5)

If Annual: LICENSE#: |__|__|__|__|__|__|__|__| EXP. DATE: |__|__/__|__/__|__|

AGE: _____ SEX: M__ F__

LAST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

FIRST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

STREET ADDRESS: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

CITY: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| STATE: |__|__|

ZIP: |__|__|__|__|__| PHONE#: (____)|__|__|__-__|__|__|__|

E-MAIL: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

T-SHIRT SIZE: S___ M___ L___ XL___

Extra Meals for Spectator(s) $10 each. Indicate quantity: Saturday___ Sunday___

Extra Camping for Spectator(s) $5 per night per person. Saturday___ Sunday___

EMERGENCY CONTACT INFO:

NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

PHONE#: (____)|__|__|__-__|__|__|__| or SPECTATOR AT THE EVENT ___

OPTIONAL:

TEAM/SPONSOR: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

OCCUPATION: _______________

TIDBIT ABOUT YOURSELF: _____________________________