Henry Guidry Memorial Park
103 Park Drive, Henderson, LA 70517
• 30 Mile Organized Bicycle Ride
• Scenic Road Course
• Registration: 7:00 am
• Start Time: 8:00 am
• $30 Entry Fee
• Contact Ashley Stelly 337.351.2496
All proceeds benefiting the Michael Fitzgerald Benefit Fund.
REGISTRATION FORM – Please Print
Full Name: Phone:
Emergency Contact Name: Emergency Phone No.
Rider Signature: Date:
Parent/Guardian (under 18):
Mike Fitzgerald, a longtime Schilling Distributing Co. employee and resident of Cecilia, was tragically struck while on a bicycle ride workout near Saw Mill Road, in January of 2010.
Mike is suffering from multiple brain and bodily injuries along with visual deficits.
Friends and family have organized a benefit to help defray mounting medical costs,
as Mike continues down his lengthy road to recovery.
Required Waiver: I fully realize the dangers of participation in a bicycle ride, and fully assume the risks associated with such participation including, by way of example and not
limitation, the following: the danger of collision with pedestrians, vehicles, other riders and fixed or moving objects; the danger arising from surface hazards, equipment failure,
inadequate safety equipments, and weather conditions; and the possibility of serious physical and/or mental trauma or injury associated with athletic cycling competition. I hereby
waive, release and discharge for myself, my heirs, executors, administrators, legal representatives, signer and successors in interest (hereinafter referred to as “successors) any and all rights and claims which I have or which may hereafter accrue to me against the sponsors of this event, the organizers and any promoting organizations, property owner, law
enforcement agencies, all public entitles and special districts, through or by which the event will be held for any and all damages which may be sustained by me directly or indirectly in
connection with the event, or travel to or return from the event. I agree it is my sole responsibility to be familiar with the ride course and special regulations for the event, and I further agree not to sue sponsoring organizations for this event. I understand and agree that situations may arise during the ride which may be beyond the immediate control of the ride
officials or organizers and I must continually ride so as to neither endanger myself nor others. I accept responsibility for the condition and adequacy of my equipment. I will wear a
helmet. I have no physical or mental condition, which, to my knowledge, would endanger myself or others if I participate in this event, or would interfere with my ability to participate in
To pre‐register, please mail in form
and payment no later than May 4th to:
Michael Fitzgerald Benefit Fund
1002 Clay Courville Rd.
Breaux Bridge, LA 70517
Henry Guidry Memorial Park
103 Park Dr. Henderson, LA 70517
May 15th, 2010