4th Annual Tour de Coal
Saturday September 26, 2009
Release: I hear-by wave all claims against the Coal Country Chamber of Commerce, the City of Benld
and the sponsors and volunteers associated with the Tour de Coal.  I attest that I am 18 years of age or
older.  I further attest that I am physically fit and prepared to participate in this event, that I will wear a
helmet and I will obey all traffic laws.



                                                                                                                                                    
Signature of participant, parent or guardian                                                                 Date


Please send a check or money order for $15 per person / $40 per family along with this
printed form (Payable to the Coal Country Chamber of Commerce) to the following address:
                     Coal Country Chamber of Commerce
                     P.O. Box 57  
                     Gillespie, Illinois 62033

Please mail Registration form no later than Thursday, September 17, 2009
Street Address Apartment
City State Zip Code
Telephone Email
Printable Registration Form
Choose your Ride:
T-Shirt Size (each registered cyclist will receive a t-shirt)
S Qty. M Qty. L Qty. XL Qty. XXL Qty.
PLEASE BE SURE TO ORDER YOUR T-SHIRTS CORRECTLY!!!
Name (First) (Middle) (Last)
Gender Birthdate (M) Day Year
I am 13 years of age or older
Initials of parent or guardian required for children 13 to 17 years of age
Emergency Contact Relation Contact Telephone
Fill out form online, then click the 'Print' icon at the top of your browser