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Name___________________________________ Address_________________________________ City___________________ State____ Zip______ Phone________________ Age______ Ride(Circle One) 200K 100Mi 100K 25Mi |
Ride Cost:....................................................$_______ T-Shirts (Mark Qty next to Size) $15 each S_____ M_____ L_____ XL_____ ..... $_______ Extra Dinners(Non-Riders) $5 each.........$_______ Extra Dinners(13 & Under) $2.50 each....$_______ Total.............................................................$_______ |
Accident Waiver and Release of Liability
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I acknowledge that this athletic event is an extreme test of a person’s physical and mental limits and carries with it the potential for death, serious injury and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of athletes, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to athletes, but are also present for volunteers. I hereby assume all of the risks of participating and/or volunteering in this event. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault.
I certify that I am physically fit, have sufficiently trained for participation in the event and have not been advised otherwise by a qualified medical person. I acknowledge that this Accident Waiver and Release of Liability form will be used by the event holders, sponsors and organizers, in which I may participate and that it will govern my actions and responsibilities at said events.
In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) Waive, Release and Discharge from any and all liability for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to me including my travelling to and from this event.
I hereby consent to receive medical treatment, which may be deemed advisable in the event of injury, accident and/or illness during this event. I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and/or assigns. This Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I hereby certify that I have read this document; and, I understand its content. |
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| Print Participant's Name | Age |
Signature (If under 18 years old, parent or guardian must also sign) |
Date |
| The undersigned parent and natural guardian or legal guardian does hereby represent that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, cost, claim or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act an release said parties on behalf of the minor and the parents or legal guardian. |
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| Print Parent or Guardian Name | Age | Signature of Parent or Guardian | Date |