MX SCHOOL 2008

NAME OF RIDER _________________________AGE_________________

PARENT/GUARDIAN______________________________________

EMERGENCY CONTACT___________________________________

BIKE MODEL __________________CC_______________

WEEK SELECTED__________________________

MC/VISA #______________________________EXP DATE__________

CVC CODE__________ BILLING ZIP___________

__________________________________________________________

SIGNATURE OF CARDHOLDER                                DATE

• EACH STUDENT/RIDER MUST HAVE A LIABILITY WAIVER SIGNED BY THE PARENT/GUARDIAN. (CUSTODIAL PARENTS ONLY)
• BRING A COPY OF MEDICAL INSURANCE
• RIDER WILL NEED CASH/CREDIT FOR GAS, REPAIRS, SNACKS..ETC.

FAX TO: 706-486-4688

EMAIL TO: anita@durhamtown.com