Sunday, September 16, 2007 -- Rio Grande, OH / Bob Evans Farm
Bob Evans Farm Fall Festival Cross Country
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Mail with payment to: Jon F. Burris, Ohio Valley Bicycle Club, P.O. Box 63, Gallipolis, OH 45631
ACCIDENT WAIVER & RELEASE OF LIABILITY - RACE REGISTRATION FORM NAME: ____________________________________________________ AGE:_____________ DATE OF BIRTH: ____________ ADDRESS: _________________________________________________ CITY: ____________________________________________________ STATE: __________ ZIP:________________ PHONE#: (_______________)__________________________________ E-MAIL ADDRESS: ___________________________________________ EMERGENCY CONTACT: ________________________________________ EMERGENCY PHONE#: (_____________)__________________________ RACE CLASSES: ENTRY FEE OF $26 required to be paid with this form. Mail yours to get your T-SHIRT! [ ] PRO/EXPERT MEN [ ] VETERAN 45+ [ ] JUNIOR/SCHOOLBOY (15-18) [ ] PRO/EXPERT WOMEN [ ] MASTERS 55+ [ ] CLYDESDALE (200+lbs) [ ] SINGLE SPEED OPEN [ ] MENS SPORT [ ] BEGINNERS (one lap only) [ ] VETERAN 35+ [ ] WOMENS SPORT [ ] KIDS (12-14)&(12-Under)(participation permitting)
* I acknowledge that this athletic event 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, event vendors and producers of the event. These risks are not only inherent to athletics, but are also present for volunteers. I hereby agree to assume all of the risks of participating and/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 property owned, maintained or controlled by them or because of their liabilities without fault.
* I certify that I am physically fit, have trained sufficiently for this event and have not been advised otherwise by a qualified medical person.
* I acknowledge that this Accident Waiver and Release of Liability (Waiver) 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 event.
* In consideration of my application 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 liability for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter accrue to me including my traveling to and from this event. THE FOLLOWING ENTITIES OR PERSONS: The Ohio Valley Bicycle Club, Bob Evans Farms, University of Rio Grande affiliated organizations and any involved municipalities, their directors, officers, employees, volunteers, representatives or agents, the event holders, event directors, event sponsors, event volunteers, property owners: B) Indemnify and hold harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this event, whether caused by the negligence of releases or otherwise.
* 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 become photographed and I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, organizers and/or assigns.
* This Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum permissible under applicable law.
* I further agree to abide by all the rules and regulations as set forth by the director of this event.
* I hereby certify that I have read this document and understand its contents.
ENTRANTS SIGNATURE: ______________________________________________ DATE: _____________________
(Note: If entrant is age 17 or under, Signature of Parent or Guardian is required below) the undersigned parent and natural guardian or legal guardian does hereby represent that he/she is in fact acting in such capacity and agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, claim or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.
SIGNATURE OF PARENT OR GUARDIAN____________________________________ DATE: ___________________
MEAL TICKET AND PRIZE DRAWING (one voucher per participant)
Please leave this voucher attached for the registrar when you pick up your numbers. The registrar will remove it and return it to you to use at the concession for a free meal. One meal is allowed per entrant. The stub on this voucher will be removed by the race Director/registrar and placed into a drawing that will take place after the event. One Prize is allowed per entrant in the drawing.
RACER NUMBER:__________________________________