Make checks payable to The West Georgia 100
Mail to: WG100 c/o eNetFirst, Inc., 1002 Maple Street, Carrollton, Ga 30117

Rider's Name___________________________ Address_________________________________
City____________________________________ State________ Zip______________ Sex____
Rider's Cellphone__________________________ Home Phone__________________________
Work Phone___________________________ Email Address____________________________
Emergency Contact_____________________ @ Emergency Phone # ____________________

Rider's Birthdate__________ Circle one: 12 miles   25 miles  50 miles  66 miles  100 miles

TANDEMS ONLY   Stoker's Name ____________________ Birthdate ______________ Sex____

2011 WG100 Registration and Options Workbox
ITEM	DETAILS	QTY/PRICE	SUBTOTALS
Rider Fee	$35 for Singles   $70 for Tandems	Qty One(1)	$
Junior Fee	$25    12 and Under	Qty One(1)	$
- - ->	Postmark by 5/11/11	and subtract $5	$
Additional Donation	Gratefully accepted!	- - ->	$
Rider T-Shirt	Circle Size    S    M    L    XL    XXL	Qty One(1)	Included
Stoker T-Shirt	Circle Size    S    M    L    XL    XXL	Qty One(1)	Included
T-shirts guaranteed to pre-registered riders only.
Extra Event SS T's	Size ____ Size____ Size ____ Size____	#____@ $12.50 ea	$
GRAND TOTAL INCLUDED (checks and money orders only) Payable to The West Georgia 100			$

By affixing my signature I attest that I have read and agree to the West Georgia 100 Liability Waiver
and I further agree to sign waivers as necessary at registration, including a copy of the WG100 Liability Waiver.

Signature____________________    Guardian sign here for under 18 years_____________________

TANDEM ONLY
Stoker Signature____________________   Guardian sign here for under 18 years____________________

Ride Starts at 8:00 am May 27, 2012 - Ride will be held rain or shine - NO REFUNDS!
Sag stops and mechanical assistance provided on all routes.
Courses will be marked and maps provided.