St. Michaels Historic Century
Please print and complete this document and send signed copy to:
Bayside Velo, c/o Bike Doctor, 953 Ritchie Highway, Arnold, MD 21012
Last Name First Middle
Street Address City State Zip
Telephone Email Age Club Membership
[_] Male [_] Female Circle T-shirt size:: S M L XL XXL
[_] Tour (30 miles) [_] Metric Century (62.5 miles) [_] Full Century (100 miles)
Registration Fee (Includes T-Shirt $38.00 $
and Refreshments.) $45.00 (after 8/1/06)
Please Note: Late registration cost above . Grand Total: $
Ride is Limited to 500 riders.
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If you are using a credit card please complete the following: [_] MasterCard [_] Visa Card Number [_] [_] [_] [_] [_] [_] [_] [_] [_] [_] [_] [_] [_] [_] [_] Exp. Date ____________________ Signature _______________________________ |
Include self-addressed stamped envelope with application for confirmation. Make check payable and mail with registration form to Bayside Velo, 953 Ritchie Hwy. Arnold, MD 21012
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT (“AGREEMENT”):
In consideration for being permitted to participate in any way in the 2006 St. Michaels Century (“ACTIVITY”) on September 16, 2006, an event sponsored by Bayside Velo, I, for myself, my personal representatives, assigns, heirs and next of kin: 1. ACKNOWLEDGE, agree and represent that I understand the nature of bicycling activities and that I am qualified to participate in such Activity. 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. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity. A. UNDERSTAND that all participants in the Activity are required to wear BICYCLING HELMETS, and I agree to wear a bicycle helmet while riding a bicycle as part of any event connected with the Activity. 3. FULLY UNDERSTAND that (a) BICYCLING ACTIVITIES INVOLVE RISKS and DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH (“RISKS”); (b) these Risks and dangers may be caused by my own actions, or inactions, the actions of inactions of other participants in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE ‘RELEASE’ NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS AND DAMAGES I incur as a result of my participation I the Activity. 4. HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS Bayside Velo, its administrators, officers, volunteers, staff, agents and employees; other participants; and any other sponsors, advertisers and , if applicable, owners and leasers of premises on which the Activity takes place (each considered on the “RELEASES” herein) FROM ALL LIABILITY, CLAIMS, LOSSES OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE “RELEASES” OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS.
I have read this agreement, fully understand its terms, understand that I have given up substantial rights by signing it and have signed it and have signed it freely and without any inducement or assurance of any nature and intend it to be complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to
be invalid that the balance, notwithstanding, shall continue in full force and effect.
Participant’s Signature Emergency Contact
Signature of Parent/Guardian (if under age 18) Emergency Telephone