Name:___________________________________________________________________________
Address
_________________________________________________________________________
City:__________________________________________
State:________ Zip:_________________
Phone: (H
):(_____)_______________(W) (___)_______________
Club
Affiliation:___________________________________________________________
email:___________________________________________________________________
Randonneurs
USA number: _________________
Membership in Randonneurs USA is encouraged and
will be required for anyone wishing to receive a
French Brevet medals. You may apply directly by completing the Randonneurs USA application form.
Indicate "applied for above if you have previously applied and are
awaiting confirmation Notify
Brevet Organizer of your Randonneurs USA number when it is received.)
Events Entered/Entry
Fees
200 KM
$12.00..............$ __________
300 KM
$12.00..............$ __________
400 KM
$15.00..............$ __________
600 KM
$25.00..............$__________
All
four brevets $50.00
..$___________
Total..............$ ___________
Medals can be purchased directly from RUSA.
Make
checks payable to North Carolina Bicycle Club (NCBC) and mail them with the
entry form to:
Alan Johnson
308 Ashe St.
Morrisville, NC 27560
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:
____________________________________________________
Date:
__________/____________/______________________
You
must be 18 or over or under the supervision of a parent or guardian