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Beaumont Moonlight Madness Registration

15th Annual
Moonlight Madness Registration
Bike & Skate
May 24, 2013             10 pm             Rodgers Park                            
                                                             Dowlen Rd @ Gladys


Street Address                                                                                                         

City, State, Zip                                                                                                          

 Phone Numbers H-                                                      O-                                          

      T-ShirtSize:          Adult            SM      MED     LG     XL     XX  
                           Youth     YS     YL

Register Early:    $8. (No Shirt)         $15.  w / Shirt    

After May 17th:  $12. (No Shirt)         $20.  w / Shirt    

      Amount Paid      .  
Make Checks
Payable to:        Beaumont Parks & Recreation
                            PO Box 3827
                            Beaumont, TX 77704

Release & Indemnity
      In consideration for allowing me to participate in the “Moonlight Madness” bicycle event sponsored by the City of Beaumont through its Parks Departments, I do hereby release  the City of Beaumont, its officers, agents, or employees, from any claim, suit, cause of action or loss which may have arising out of my participation in the “Moonlight Madness” bicycle event. I further state that the indemnity provided herein includes against the negligence of the City of Beaumont, its officers, agents and employees.

Participant or Legal Guardian if under 18 years old
Saved as: Rides\Moonlight Madness Registration 5.25.99.wpd