WEDNESDAY JULY 4, 2012

• WHERE:   KOKOMO CYCLING & FITNESS
• WHEN:   MASS START AT 8:00 AM
• PRE-REGISTRATION DEADLINE:   JUNE 26, 2012
• DETAILS:  The registration table at Kokomo Cycling & Fitness will open at 6:00 AM.
  The ride starts at 8:00 AM.
  All riders must be off the course by 4:00 PM
  One of the Break-Away Bike Club's yearly favorites.
  A flat to gently rolling course that will take you past or through;
  Galveston, the Mill at Pipe Creek Falls, Mississinnewa & Wabash rivers, Peru, Bunker Hill & Miami.
  This is traditionally a very HOT ride. So drink plenty of water!
  There are two sag stops to refresh yourselves.

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NAME:__________________________________ FAMILY:_________________________________ ________________________________________ ________________________________________ ADDRESS:________________________________ CITY/STATE/ZIP:__________________________ PHONE:__________________________________ RELEASE SIGNATURE:______________________________ (parent or legal guardian for participants under age 18) EMERGENCY CONTACT:____________________ PHONE:__________________________________

All registered receive T-shirt, map, support vehicle,2 sag stops, food & refreshments. Pre- registration Fee: $20.00X_____=__________ After June 26th Fee: $25.00X_____=__________ T-Shirt (please circle) S  M  L  XL  XXL TOTAL ENCLOSED:                  $__________ Make check payable and mail to: Break-Away Bicycle Club c/o Kokomo Cycling & Fitness 1500 E. Boulevard Kokomo, IN. 46902

Release Of Organizers And Sponsors: In signing this release, I acknowledge that I understand its intent. I understand that the Break-Away Bicycle Club, Haynes Apperson Festival and their officers, members and sponsors, the cities, counties, state or district where this event is held, are not insurers of my personal safety before, during or after the event or any activities associated therewith. I thus release them and agree to hold them harmless from any and all liability arising from my having sustained any property damage or personal injury by reason of my participation in this event. I recognize the difficulties of this event and attest that I am physically fit to participate in this event and that I have not been advised otherwise by a qualified medical person. I also hereby consent to and permit emergency medical treatment in the event of injury or illness. I shall abide by traffic laws and regulations and practice courtesy and safety in cycling.