Tarwheel Registration

River City Cycling Club
P O Box 295
Elizabeth City, NC. 27907-0295

*Make checks payable to RCCC - $35.00 adult, $20.00 youth (under 16, must be accompanied by an adult). No confirmation will be sent.

For additional info call Ed 252-267-3312 (cell) or Cycle Gallery at 252-338-1559 (10:30 am to 6:00 pm)

Name: ______________________________________________

Address: ____________________________________________

City: _______________________________________________

State: _____________________Zip: __________

Phone number: ___________________

Emergency contact: __________________________________

Emergency contact phone: ___________________

I plan to ride: Third Century (33) - Metric Century (62) - English Century (100)

T-Shirt Size:  S     M     L     XL     XXL      No T-shirt

The T-shirt is guaranteed only if your registration must be received prior to April 5th.

If under 18, have parent sign for permission. Riders under 16 must be accompanied by an adult.

River City Cycling Club requires a waiver must be signed prior to ride. Please sign below agreeing to do so.

Signature/Date __________________________________________

Guardian if required _____________________________________