NC Randonneurs ride and cookout
August 15th 2009
Organized by NCBC Randonneurs
Entry Form And Accident Waiver And Release Of Liability
Name:____________________________________________________________________________________
Club Affiliation:____________________________
Randonneurs USA number: __________________
Events
Entered/Entry Fees
110 KM Populaire and picnic
$15.00..............$ __________
200 KM Brevet and picnic
$15.00..............$ __________
Medals
can be purchased directly from RUSA.
In
consideration of being permitted to participate in any way in the 200 KM brevet
(Activities or Activity) I, for myself, my representatives, assigns, successors,
and heirs represent and agree as follows:I acknowledge that this
athletic event or Activity 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 &/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 further acknowledge that the Activity will be
conducted over public roads and facilities open to the public during the
Activity and upon which the hazards of traveling are to be expected. If at any
time I believe conditions to be unsafe I will immediately discontinue further
participation in the activity.
I acknowledge that this Accident Waiver and Release of
Liability (AWRL) 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 or my traveling to and from this event, THE FOLLOWING ENTITIES OR
PERSONS:ALAN MERLE JOHNSON, NORTH CAROLINA BICYCLE CLUB,RANDONNEURS USA, (RUSA),
AUDAX CLUB PARISIEN, and RANDONNEURS MONDIAUX their directors, officers,
employees, volunteers, representatives, and agents, the event holders, event
sponsors, event directors, event volunteers; (B) Indemnify and Hold Harmless the
entities or persons mentioned in this paragraph from any and all liabilities or
claims made by other individuals or entitles as a result of any of my actions
during 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 AWRL 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. I understand that I have given up substantial rights by
signing this AWRL and have signed it freely and without any inducement or
assurance of any nature.
Signature:
___________________________________
You must be 18 or over or under the supervision of a parent or guardian