REGISTRATION FORM

You may use this form to email your registration information to us or download and mail the printable registration form (see link in right column)..
You will need to pay the indicated fees at the event or by mail, prior to praticipating in the rally. We take Visa, MasterCard, Discover, American Express, checks, and good old cash.
All fields must be completed.

*Name: A value is required.

Address: A value is required.

City:
A value is requir

State:
AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Please select a state.

Zip:
A value is required.Invalid format.

Phone: A value is required.

*Email: A value is required.Invalid format.

Saturday morning ride choice:
Speed = 25-30 miles @ 16 mph + pace)
Scenic = Location TBD

Please choose one. Speed Scenic. Please select an item.

Storage - Number of Recumbents per night
($5 each night):

Friday Night: Invalid format.   Saturday Night: Invalid format.

Release and Waiver of Liability:

In submitting this form, I acknowledge that I understand its intent, and I for myself, my heirs, executors, administrators and representatives, do hereby agree and will absolve and hold harmless Easy Street Recumbent, LLC, corporate sponsors, cooperating organizations and any other parties connected with this event in any way together with their respective successor and assigns (the sponsors) singly and collectively, from and against any blame and liability for any injury, harm, inconvenience, or any other damage of any kind whatsoever, which may result from or be connected in any way to my participation in the Heart of Texas Recumbent Rally. In addition to the absolute and unqualified release from all liability, I hereby represent that I am physically capable of participating in this event, that my bicycle, tricycle, and any other equipment I may use to participate in the event are in working condition, and I will observe all applicable traffic and event rules and that I will wear a helmet and generally conduct myself in a safe and prudent manner while participating in the event and I hereby absolve and hold harmless sponsors from any damage I may sustain because of any breach of these representations. I hereby Consent to and permit emergency treatment in the event of injury or illness while participating in the event. I also hereby give permission to the Easy Street Recumbents to use my name and pictures/video taken.

Please enter the number "2012" (two zero one two) in the following text box. This is an anti-spam action. Thank you: A value is required.Invalid format.