Registration Information:    Name___________________________    D.O.B _______  Male/Female_______  T-Shirt S-M-L-XL____

 

                                              Address__________________________  City_____________ ST ____   ZIP_______

 

                                              Email___________________________    Ph_________________  ZIP Code_________

 

                                              Emergency Contact Name_______________________________  Ph______________

 

ACCIDENT WAIVER AND RELEASE OF LIABILITY

 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 athletics, 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 traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS:  Bicycle Greene VA, their directors, officers, employees, volunteers, representatives, and agents, the event holders, event sponsors, the event beneficiaries, event volunteers; (B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this event, whether cause by the negligence of releases or otherwise.

 

I hereby consent to receive medical treatment that 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 assigns.

 

The 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 it’s content.

 

 Print Participant’s Name _____________________________________    Age____________

 

  Signature_____________________________________________              Date___________

                     (If under 18 years old Parent or guardian must sign)

 

AGREEMENT OF PARTICIPATION FOR MINORS (Under 18 years old)

The undersigned parent 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 and release said parties on behalf of the minor and the parents or legal guardian.

 

Print Name of Parent of Legal Guardian _______________________________________________

                       

Signature of Parent or Guardian_______________________________________    Date_________