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NUMB 2012 Registration

NUMB 2012 a 275+/- mile loop tour starting and ending in Beatrice, Nebraska, June 23 - 27. The official start of NUMB 2012 is the Saturday evening Rider’s Meeting, but for those arriving early to Beatrice, there will be an optional pre-NUMB loop ride on Saturday morning of approximately 39 miles that includes a visit to Homestead National Monument. The ride is a fund raising event to motivate donors to contribute to alleviating hunger all around the world. For more information go to the NUMB 2012 website. Registration is $50 ($55 after May 1), with each rider raising a minimum of $100 in pledges to hunger programs. Register now and you have the option of paying by Paypal on this site or send your registration fee by mail.
*First Name
*Last Name
*Email
*Preferred Name
*Address 1
*City
State
*Zip
*Phone
Cell Phone #:
*Date of Birth
*Age (as of 6/23/12)
*Sex
*May all information be sent via e-mail?
Yes
No
*T-shirt size:
Extra t-shirt order: ($10) Extra t-shirt order. Each registrant receives one t-shirt. Please fill in the number of extra t-shirts you would like to order.
Size(s) of Extra T-shirt(s):
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Please name the United Methodist Church you attend (church name and city, if applicable).
I will be there for the optional day on Saturday.
Yes
No
No answer
*This is my first NUMB!
Yes
No
If this is not your first how many times have you been on NUMB?
*Mechanic information (type and make of bike): If volunteering - please write volunteer
I would like to volunteer.
I won't be riding, but I would like to help with support. (No fee, volunteers will be sent additional information.)
*Registration Fee ($50) Pay your registration fee online by choosing the "Pay Now" button once you've submitted your registration. Or send a check to: NUMB c/o Regina Bergman, 4113 N 213th Cir, Elkhorn, NE 68022
Check # and/or note (if mailing registration)
I would like to make a donation to the hunger projects supported by NUMB, right now.
Please select an amount for your donation.
($25)
($50)
($100)
In case of emergency—please contact:
*Name:
*Relationship to you:
*Phone number:
I agree to the terms and conditions outlined below. I freely acknowledge and realize the dangers in participating in NUMB '12 and fully assume all risks including but not limited to, collision with pedestrians, vehicles, other riders, and/or fixed or moving objects, the negligence of other riders, sponsors, promoters or drivers and dangers arising from falls, road surface, equipment failure, inadequate safety equipment, weather conditions, as well as the possibility of physical and/or mental trauma (or injury). I understand that the route requires bicycling on public roadways and in bad weather and that cyclists have been hospitalized and/or killed because of traffic mishaps that are either their responsibility or others’ responsibility, and I further agree that I will bear all expenses incurred in any such accidents. I realize that NUMB requires physical conditioning and I represent that I am in sound medical condition. I have no physical or medical impediment, which would endanger others or myself. I understand and agree that a situation may arise during NUMB which may be beyond the control of the sponsors, promoters, or organizers and agree to ride so as not to endanger either others or myself. I waive, release, discharge for myself, my heirs executors, administrators, legal representatives (including successors), any and all rights and/or claims which I have, may have, or may hereafter accrue to me against the sponsors and promoters of NUMB including the United Methodist Conference or other sponsors or affiliated organizations and their respective agents, officers and employees for any and all damages, injuries, or claims which may be sustained by me directly or indirectly arising out of my participation in NUMB. The above agreements and representations are my express understandings of the risks, and I assume these voluntarily and freely without coercion or duress. This agreement may not be modified orally and may not be waived in any respect. I accept responsibility for the condition and adequacy of my bicycle and agree to abide by the rules of NUMB relating to the wearing of a helmet as well as other organization requirements: I authorize the use of my name, photos or videos of myself to be used by NUMB or any associated organization for the purpose of promoting NUMB and I hereby disclaim any and all rights to such photos or videos. There is no time limit in hours day or years that my photo image may not be used. I also understand NUMB will only use my photo or image in publicity related to NUMB.
Person responsible for minor on NUMB 2012 If you are a minor (under age 18), please list the person responsible for the you during the ride. IMPORTANT: Applications for persons under 18 years-of-age must be accompanied by the application of their parent or person responsible for them during the 2012 NUMB Ride. This is a required field for minors.
Parent/guardian permission. I have the permission and consent of my parent(s) and/or guardian(s) to participate in NUMB 2012. I further agree that my parent(s) and or guardian(s) agree to the terms described above. A waiver will be sent to you to have both parents sign and bring with you to NUMB check-in.
Special Considerations Needed:
Additional people on the ride with you. To help in planning for meals etc, we would like to know if you will have additional people with you. If you do not know at this time, please be sure to contact us and let us know. If they would like to volunteer that would be great.
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