Name Address

City, State, Zip Code

Phone Number

E-mail Address

Age Allergies

I am interested in a Long Sleeve T-Shirt Size

(Send $15 check payable to "Dan Barz", c/o 5648 Mohican Dr., Stevensville, MI 49127 by May 5.)

Emergency Contact Person

Emergency Phone Number

Release Statement: In marking the statement below, I understand and agree to absolve all the sponsors and organizers of all blame for any injury, harm or loss suffered as a result of taking part in the Blossom2Ride.

I have read and agree with the Release statement _________________________________