"2012 tour du pap registration"
Contact Information Name:____________________________________ Mailing Address:____________________________ City:______________________________________ Prov/State:________________________________ Post/Zip:__________________________________ Country:__________________________________ Phone:____________________________________ E-mail:____________________________________ Local Address (if different than above):_____________________________________________________ Local Phone (if different than above):_______________________________________________________ Athlete Information Male Female First-Time (Tour du Port au Port)? Mother? Father? BNL Number:______________________________ Date of Birth (mm/dd/yy):____________________ MCP:_____________________________________ Medical Conditions:_____________________________________________________________________ Medication:___________________________________________________________________________ Emergency Contact (name & phone):_______________________________________________________ Event Categories Select the appropriate category: A-You live on your bike B-Weekend Warrior C-You get out when you can D-Is there really padding in those shorts? Select an event category/distance: Short distance C&D only (approx. 60 km) Long distance A&B (115km) Long distance C&D (115km) Time trial A&B (15km) Time trial C&D (15km) Event Details Date: Saturday, August 18th Location: Stephenville-Port Harmon Registration Time: 9:00 a.m. Time Trial start time: 10:00 a.m. Date: Sunday, August 19th Registration Time: 9:00 a.m. Categories C&D 115 km Race Start: 10:00 a.m. Categories A&B 115 km Race Start: 11:00 a.m. Categories C&D 60 km Race Start: 12:30 p.m. Start/Finish Location: Our Lady Mercy Complex Banquet: 4:00 p.m. at Our Lady Mercy Complex Event Fee and Payment Early bird rate with time trial (Before August 12th): $50.00 + BNL Membership th Early bird rate without time trial (Before August 12 ) $40.00 + BNL Membership th Regular rate without time trial (After August 11 ): $50.00 + BNL Membership Select a method of payment: Cash Cheque* Debit Visa Mastercard *Please make cheques payable to “Cycle Solutions Events” If paying by credit card, please complete the following information: Card Number:______________________________ Expiry Date:____/____ Name on Card:_____________________________ CVC # (3-digit back of card):___________________ Signature:_____________________________________________________________________________ Release of Liability, Waiver of Claims, Assumption of Risk and Indemnity Agreement By signing this document you will waive certain legal rights including the right to sue. PLEASE READ CAREFULLY! Athlete’s Name: ___________________________________________ (Please Print Clearly) Assumption of Risk I am aware that the Cycle Solutions Cycling Group (hereinafter referred to as “the Cycling Club”) have in addition to the usual dangers and risks inherent to the sport of cycling, certain additional dangers and risks including, but not limited to, the danger and risk of collision with natural and man-made objects and with other cyclists and spectators and I freely accept and fully assume all such dangers and risks and the possibility of personal injury, death, property damage or loss resulting there-from. Release of Liability In consideration of the Cycling Club permitting my participation in the Cycle Solutions Cycling Group, racing and other events (hereinafter referred to as “the Program”), I hereby agree as follows: 1. TO WAIVE ANY AND ALL CLAIMS that I may have against the Cycling Club, the event, the event sponsors, and their directors, officers, employees, agents, and representative, and any volunteers in any way associated with the event (all of whom are hereinafter collectively known as “the Releasees”). 2. TO RELEASE THE RELEASEES FROM ANY AND ALL LIABILITY for any loss, damage, injury, or expenses that I may suffer or that my next of kin may suffer as a result of my participation in the event due to any cause whatsoever, including but not limited to, negligence, breach of contract, breach of statutory duty of care or breach of any other duty of care. 3. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability from property damage or personal injury to any third party, resulting in my participation in the event or use of the Cycling Club and its facilities; and that, this Release of Liability shall be effective and binding upon my heirs, next of kin, executors, administrators and assigns in the event of my death. I am the full age of eighteen (18) years and I have read and understood this Release of Liability prior to signing it, and I am aware that by signing this Release of Liability I am waiving certain legal rights which I, or my heirs, next of kin, executors, administrators, and assigns may have against the Releasees. Signed this ________ day of __________________, 20____ Signature of Athlete Signature of Witness Signature of Parent/Guardian (if athlete is under 18)