Name(Last)________________________________(First)_______________________________Age_____

Address_______________________________________________________Birthdate________________

City_____________________________State_________Zip____________Phone____________________

Sex: M F Email:_____________________________________________________

Entry Fees: $15 prior to two weeks before race $20 thereafter and race day

March 21___ April 11___ May 16___ Distance: 20K___ 40K___

Release of Responsibility:_____________________________________________Date____________

                                                 Signature (parent or guardian if under 18)

Make Checks payable and mail to Headfirst Performance, 7024 Buckcreek Rd., Finchville, KY 40022

In Consideration of the acceptance of my entry in the Shelby County Time Series

I hereby agree to comply with all the rules and regulations and event instructions of the Shelby County Time Trial Series and its directors.

For myself, my executors administrators, heirs, next of kin, successors and assigns, I HEREBY:

(a)waive and release any and all claims that I may have against the Shelby County Time Trial Series, its event committee, Their officers, directors, members, volunteers, employees, sponsors or any one or more of them their executors, administrators, heirs, next of kin, successors or assigns("their releases") including any and all claims for damage caused by the negligence of any of them, arising out of my participation in the event and its related activities, together with any cost, including attorney’s fees, that may be incurred as a result of any such claim whether valid or not, and (b)indemnify and hold harmless the releases and each of them against any such claim that I or my guest or any one or more of my or their executors, administrators, heirs, next of kin, successors or assigns may have or assert and against any cost including attorney’s fees with respect thereto.

I hereby acknowledge that I have sole responsibility for my personal possessions and athletic equipment during the event and its related activities.

I hereby acknowledge that participation in this event carries with it potential hazard. I therefore release the Shelby County Time Trial Series, its event committee, their officers, directors, members, volunteers, employees or sponsors of any liability resulting from injury or death during the event and its related activities.

I hereby attest and verify that I am physically fit and have sufficiently trained for this competition and that my physical condition has been verified by a licensed medical doctor.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during the event.

I hereby agree that in the event of race cancellation due to storm, rain, inclement seas, or weather, winds or other "Acts of God" conditions, my enrollment fee shall be non-refundable.

Signature:________________________________________________Date______________________

                               Parent of guardian if under 18