A Century for Timmy

Attendees

First Name: *

Last Name: *

Name as it will appear on Name Tag: *

Email Address:

Phone Number: *

Age @ start of event: *

Address

Street Address *

Address continued

City *

State *

Zip *

Lodging

We will be doubling up riders for the Sunday Night stay during the tour. If you have a preference for whom you will share your room, please list that rider in the space provided below. If you plan on staying on Saturday night, the cost of the room is billed to the participant. Please indicate below if you would like to make your own reservations for Saturday night or if you would like us to do this for you.

Preference on who you room with:

Would you like for us to make your Saturday night reservations? * YesI will make my ownWill not be staying on Saturday Night

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AN INDEMNITY AGREEMENT

In consideration for being permitted to participate in any way in this bike tour on October 10-11, 2010, an event sponsored by Timmy’s Fund, I, my personal representatives, assigns, heirs, and next of kin:

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 on the North Bend Rail Trail in which makes several public road crossings during the Activity and upon which the hazards of traveling are 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
FULLY UNDERSTAND that (a) BICYCLING ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH; (b) these Risks and dangers may be caused by my own actions, or inactions of others participating in the Activity, the condition in which the Activity takes place, or the NEGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILTY FOR LOSSES, COSTS AND DAMAGES I incur as a result of my participation in the Activity.
HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE TIMOTHY QUIGLEY FOUNDATION, INC., its administrators, directors, ride leaders, volunteers, agents, employees, other participants, any sponsors, advertisers, and if applicable owners and releasers of premises on which the Activity takes place (each considered one of the ‘RELEASEES’ herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR PART BY THE NEGLIGENCE OF THE ‘RELEASEES’ OR OTHERWISE, INCLUDING NEGLEGENT 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 FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY THE LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
I further agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event producers, event sponsors and/or assigns. I attest to the fact that I will be at least 18 years of age at the start of the tour, or that I am not at least 18 years of age and that my parent/legal guardian has signed the parental consent in the following paragraph.

By checking this box, you are electronically signing this WAIVER. * I agree with the Release and Waiver of Liability and Assumption of Risk

PARENTAL CONSENT

I have read the above RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT and understand that this tour is being put on for the benefit of THE TIMOTHY QUIGLEY FOUNDATION, INC., and request my son/daughter be allowed to participate. By signing this PARENTAL CONSENT I am agreeing that the above RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT shall pertain in total to my son/daughter. This shall include the consent for medical care should it be necessary, and consent for use of photographs and/or videotape in legitimate ways. I understand that any participant under the age of 16 needs to be accompanied by a responsible adult.

By checking this box, you are electronically signing this PARENTAL CONSENT. I agree with the PARENTAL CONSENT AND RELEASE AND WAIVER OF LIABILITY

Relationship to Participant:

Date:

HELMENT AGREEMENT

I agree that I will properly wear a CPSC approved bicycle helmet at all times while I am riding a bicycle during this event, and that I seek to obey all laws pertaining to my safety and the safety of others, and will seek to conduct myself in a responsible and safe manner throughout the duration of the tour.

By checking this box, you are electronically signing this HELMET AGREEMENT. * I agree with the HELMET AGREEMENT

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