2011 FORT COLLINS VELODROME ASSOCIATION
ACCIDENT WAIVER AND RELEASE OF LIABILITY
As a participant, I acknowledge that the above referenced cycling event(s) will be an extreme test of my physical and mental limits and involves the potential for death, serious injury and property loss. The risks include, but are not limited to, those caused by the condition of the cycling surfaces, facilities, temperature and weather conditions, my physical condition and that of other cyclists, my equipment and that of other cyclists, vehicular traffic, conduct of other people including, but not limited to, other cyclists, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event. I further acknowledge that the said cycling event(s) will be held at an elevation above sea level that may require greater endurance and a greater need for hydration than I and other cyclists may be used to, thereby potentially increasing my risk of physical injury or death. I hereby knowingly assume all of the risks of participating in said event(s). I understand and accept that liability may arise from negligence or carelessness on the part of the persons or entities being released, or from dangerous or defective equipment or property owned, maintained or controlled by such persons or entities, or because of their possible liability without fault because of conditions or circumstances beyond their control. I certify that I have sufficiently trained for participation in the event(s), that I am physically and mentally capable of participating in the event(s), and that I have not been advised otherwise by a qualified medical person. I acknowledge that this Accident Waiver and Release of Liability form will be used and relied upon by the event holder, sponsors, and organizers for the cycling event(s) in which I participate, and that it will govern all circumstances and occurrences in which I am involved during my participation in said event(s).
In consideration of my application and permitting me to participate in the event(s), I, for myself and my executors, administrators and heirs, do hereby: a) waive, release and discharge from any and all liability for loss, claims, or causes of action for my injury, disability, or death, and for property damage or property theft, which may arise out of or be connected in any way to my participation as a cyclist in the event(s), Fort Collins Velodrome Association, a Colorado non-profit corporation, its members, officers, employees and agents, and the event holders, event sponsors, and event directors, volunteers and officials (collectively, the “Releasees”); and b) indemnify and hold harmless the Releasees from any and all liabilities or claims which may be made by other persons or entities as a result of my participation in said event(s).
· 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 am aware that the event(s) is not an event sanctioned by USA Cycling and USA Cycling insurance will not apply.
· I am aware that the event(s) is not an event sanctioned by the ACA and ACA insurance will not apply.
· I understand that at the event(s) or related activities I may be photographed. I agree to allow my photo, video or other likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and/or assigns, without compensation.
PARENT OR GUARDIAN FOR MINORS (UNDER 18 YEARS OF AGE)
The undersigned parent and/or natural guardian or legal guardian of a minor participant in the event(s) does hereby represent that he/she has full authority as parent or guardian of such minor, is acting in such capacity, and hereby releases, and agrees to hold harmless and indemnify, the Releasees as stated above on behalf of the minor and the parent or guardian.
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 and agree with its provisions.
| PARTICIPANT INFORMATION |
|
|
(For official use - please leave blank!) |
|
|
* |
|
|
* |
|
|
* |
|
|
* (partipant's age on December 31st, 2011) |
|
|
|
|
|
|
|
|
* |
|
|
* |
|
|
* |
|
|
* |
|
|
* |
|
|
* |
|
|
| EMERGENCY CONTACT INFORMATION |
|
* |
|
|
* |
|
|
| RACE CATEGORY REGISTRATION - (UPDATE: PLEASE LEAVE ALL BELOW VALUES AS "NOT RACING" - WE WILL COMPLETE THIS INFO AT "SIGN IN" ON RACE DAY! THANK YOU!) |
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* |
|
|
* |
|
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* |
|
|
* |
|
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* |
|
|
* |
|
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* |
|
|
* |
|
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* |
|
|
* |
|
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* PLEASE LEAVE BLANK! WE WILL COMPLETE THIS INFORMATION AT REGISTRATION THE DAY OF RACES! THANK YOU! |
|
|
* |
|
|
* |
|
| RAIN DATE IS SET FOR JUNE 26th! |
|
|
|
|
|
|
|
|
|
* |
|
|
|
|
| Registration Fee:
Juniors (kids under 18 years of age) race for FREE in the junior categories. Those age 16+ racing in adult categories (with guardian permission) pay the fee given below.
Minimum 18+ categories is $10 per categories per event day; second category is $5.
CSU RAM CYCLING TEAM members and ANY VOLUNTEERS race for HALF the fees given above! |
|
|
|