ELECTRONIC REGISTRATION FORM
GOOD SAM BIKE JAM

Please fill out this form in its * entirety and click SUBMIT.
The registration form will be sent to the Foundation Office
for processing. You will be contacted for payment details.
If you wish to download and print a registration form click HERE.

* First Name:
* Last Name:
* Address1:
Address2:
* City:
* State *ZIP
* Age:
Male Female
* E-mail:
 
To receive pre-event updates only; we respect your privacy
* Phones:
Day Evening Emergency
* Select Route:
62 Mile Course 40 Mile Course Family Fun Ride
 
Fee Schedule
All proceeds benefit Cardiac Care at Exempla Good Samaritan Medical Center
   
Number:
 
 $
Number:
 
$
Number:
 Family Fun Ride $15 per rider
$
 
 Additional Donation in Support of EGSMC Foundation
$
 
$
   
 
 Free Ride T-Shirt: (adult sizes) S M L XL XXL
   Riders who register by 9/3/07 are guaranteed an event t-shirt.
 Riders who register after 9/3/07 will receive a t-shirt as supplies last.
 
*Initials of Entrant Date (All participants must initial)
Name of Parent for Entrant under 18 years Date
 

Registration fee: Includes map, route markings; aid stations; light snacks and drinks and sag support. All registration fees and collected contributions are non-transferable and not refundable under any circumstance, including, without limitation, my failure to participate in the Good Sam Bike Jam, for any reason, or the cancellation or rerouting of the Good Sam Bike Jam bicycle ride due to reasons beyond the control of the Exempla Good Samaritan Medical Center Foundation, (such as road closures or forest fires).

All registrants clicking SUBMIT on this form
represents an agreement to the following:

ASSUMPTION OF ALL RISKS BY THE ENTRANT: With the full knowledge and appreciation that bicycle riding is a hazardous activity and in consideration of your accepting this entry, I, intending to be legally bound for myself, my heirs, executors, and administrators, waive and release any and all rights of claim for damages as I may have against the Good Sam Bike Jam organizers, their agents, and towns, counties and state in which the event is run, their representatives, successors, and assigns, and for any and all injuries and/or property damage suffered by me in said event, and for the same consideration, the undersigned parent or guardian hereby indemnifies and agrees to hold Good Sam Bike Jam organizers, and their agents, harmless from any and all liabilities which may occur by the entry of the applicant in the Good Sam Bike Jam. I agree to the following: I will wear an ANSI or SNELL approved helmet at all times. I will wear my event wristband and display in a clear manner. I will carry ID. I will obey all traffic regulations, signs and lights. I will ride as far to the right side of the road as possible. I will ride single file except to pass when possible.


For Additional Information:
Call: 303-689-5251
E-mail: arnaln@exempla.org
Mail: EGSCM Foundation, 200 Exempla Circle , Lafayette , CO 80026
Fax: 303-689-5241

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