Pedal the Parkland

September 20, 2008

Application Form

 please print clearly

Name_______________________________________

Mailing address______________________________________

City____________________________________________________

State_____________Zip________

Phone (____)_______________

Cell (_____)________________

Email_________________________________

Male ___Female ___ Age _____

Emergency contact

Name____________________________

Phone (_____)_____________________

Choose a Ride

___62 mile endurance

___32 mile challenge

___12 mile mosey

___15 mile off-road scramble 

Ride Fees

____$25 Early registration

____$30 After September 1  

T-Shirt (adult sizes only) 

XS___S___M___L___XL___ 

Make checks payable to:

    Park Hills-Leadington   Chamber of Commerce

 
Send application, release form and payment to:

    Park Hills-Leadington Chamber of Commerce

  #5 Municipal Drive     

Park Hills MO 63601-2064