To join "The Century Ride Home" Charity Motorcycle Road Run, print the form, fill it out and mail with your check for $150 US, payable to The Century Ride Home. To reserve a space on the ride please send a $75 US deposit before April 15. Balance is due June 1.

Pease Print Rider Name Date of Birth Address Day Tel City ST Zip Eve Tel e-mail address Passenger Name Date of Birth Bike Info Year Make Model Color License No. Ins. Coverage? Yes No

Submit one (1) entry form per vehicle:  Make checks payable (in US dollars) to: The Century Ride Home  Mail entry to: Century Ride Home c/o Kiwi Indian Parts 17399 Sage Avenue Riverside, CA 92504 USA

Deposits must be paid before April 15 to reserve a space! RIDER REGISTRATION @ $150.00US fee or $75 deposit    Shirt Size (Circle One)  S    M    L    XL    XXL    XXXL $______ PASSENGER REGISTRATION @ $50.00US fee or $25 deposit    Shirt Size (Circle One)  S    M    L    XL    XXL    XXXL $______ TOTAL $______ Balance due June 1 $______

 
Read  this release and indemnity agreement before signing. Unsigned forms will be returned.

I hereby give up all my rights to sue or make any claim against "The Century Ride Home", Kiwi indian Parts, Roadshows, Inc., the Cystic Fibrosis Foundation, Indian Motorcycle Club International, the promoters, sponsors and all other persons, participants or organizations connected with this event for any injury to property or person I may suffer including crippling injury or death, whether such injury arises while I am preparing for or participating in the event. I know the risks to myself and/or my property, and rely on my own judgement and ability to assume all such risks or loss and hereby agree to reimburse all costs to those persons or organisations connected with this event for damages incurred as a result of my negligence. I attest that I have read this agreement and agree with all of the statements herein.

Rider Signature		Date
Passenger Signature		Date
	(Signature of Parent if Passenger in a Minor)

REFUNDS: If my entry is accepted, my deposit will be applied towards the total entry fee which will become due and payable as stated above. I understand that my deposit will be refundable in full if I cancel 60 days before the ride. I understand that a portion of my deposit will be non-refundable if I cancel after June 1, 2001. Deposits are non-refundable after June 25, 2001.