Blackhawk Bicycle and Ski Club's
                          StateLine 60

(Please print)

Name   __________________________________________________________

Street __________________________________________________________

City   _______________________________  State _____  Zip ________

Phone  _______________  Bike Club Affiliation ___________________

Ride Fee    $_____                           |
                                             | Total Paid $______
T-shirt Fee $_____  Adult Sizes  S  M  L  XL |


                Mail to:   Blackhawk Bicycle and Ski Club
                           Attn: Blackhawk StateLine 60
                           P.O. Box 15443
                           Rockford, IL 61132


Release of organizers and sponsors:
In signing this form for myself or the above named participant
(if he or she is under 18), I understand and agree to absolve
all of the sponsors and organizers, be they individuals or
organizers, singularly and collectively, of all blame for any
injury, misadventure, harm, loss or inconvenience suffered as a
result of taking part in this event or in any of the activities
associated with said event.

Signature ________________________________  Date ________________