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    Adairsville, GA

    Below is the registration form to complete. Please click HERE for a printer friendly version.
    Fill out your printed form and have with you at registration.
    Last Name:
    		 _________________________________________
    First Name:

    		 _________________________________________
    Middle Initial:
    		 _____
    Address:

    		 _________________________________________
    City:
    		 _________________________________________
    State:

    		 _________________________________________
    Zip:
    		 _________________________________________
    Home Phone No.

    		 (_____)__________________________________
    T-Shirt Size: [ ]Medium         [ ]Large     [ ]X-Large     [ ]XX-Large

    Signature (Signature of parent if rider is under 18)


    ___________________________________________________________
    Credit Card Payments:
    ALL INFORMATION BELOW IS REQUIRED
    Payments will be processed upon receipt of registration.

    Name on Card: _________________________________________
    Billing Address
    (if different from above):    		 _________________________________________
    City: _________________________________________
    State:

    		 _________________________________________
    Zip: _________________________________________

    Method of Payment (circle one):     MC      Visa      AMEX
    (Sorry, no Discover or debit cards)
    Credit Card Number:

    		 _________/________/___________
    Expiration Date: ____________
    Amount:

    		 ____________
    Email Address: ____________________________________

    American Cancer Society
    300 W. Emery Street
    Ste 106
    Dalton, GA 30720
    Fax (706) 226-7531
    Waiver: In consideration of your purposes, objectives, and work and in consideration of your permitting me to participate in your event on behalf of myself, my heirs, executors, administrators, and assigns, I hereby waive and release any and all rights and claims for damages for which I may have against American Cancer Society, the municipalities through which the event will take place, as well as any person or entity connected with the event, their heirs, executors, administrators, successors, and assigns for any and all injuries or damages which I may suffer while taking part in the event or as a result thereof.