Channel Islands Bicycle Club/Pacific Coast Highway Randonneurs 2012 Fleche

March 31, 2012 to April 1, 2012

Registration and Waiver

Directions:

fill in the form fields
print the form
write a check to Channel Islands Bicycle Club (CIBC) for $25. CIBC members deduct $5. Click here to become CIBC member. Be sure to make out a separate check for CIBC membership.
up to March 17th mail the form and check to: Foster Nagaoka 10453 Tulsa Circle Ventura, CA 93004
there is no day of registration
click the "add my name to the registered rider list" button at the bottom
this must be done regardless of how you are submitting your entry form
your complete information will be sent to the event master
only your name will be on the public rider list

Be sure to print the form before clicking the button!

Entry Fee: $25 for non-CIBC member
Entry Fee: $20 for CIBC member in good standing
Start Time: 0800
Finish Time: 0800
Finish location: CAVU at the Airport

Last Name:
First Name:
Street Address:
City
State:
ZIP:
Home Telephone:
Cell Number:
Email Address:
Emergency Name:
Emergency Number:
RUSA Number:
Home Bike Club:
Date of Birth:
Team Name:
Team Captain:
Male Female
Tandem Partner: (partner must register separately):

ACCIDENT WAIVER AND RELEASE OF LIABILITY

1. RISKS RELATED TO THIS ACTIVITY

The Channel Islands Bicycle Club's 2012 Pacific Coast Highway Randonneurs Fleche (hereinafter sometimes referred to as "Activity") is an extreme test of a person's physical and mental limits. The Activity carries the potential for death, serious injury and property loss. Risks include, but are not limited to, those caused by vehicular traffic, terrain, facilities, temperature, weather, condition of athletes, equipment, lack of hydration, and actions of other people, including, but not limited to, participants, volunteers, spectators, coaches, event officials, event monitors, and/or producers of the event. These risks are present for participants, volunteers, and all other persons in proximity to the Activity. If, at any time, I believe conditions are unsafe, I will immediately discontinue further participation in the Activity.

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 doctor. I am aware that the Activity will be conducted over public roads and facilities open to the public. The hazards of traveling on public roads and facilities are to be expected.

2. LIABILITY WAIVER AND RELEASE/EXPRESS ASSUMPTION OF RISK

I hereby assume all of the risks of participating and/or volunteering in the Activity. In consideration for being permitted to participate in, observe, or be present during Channel Islands Bicycle Club's 2012 Pacific Coast Highway Randonneurs Fleche, I RELEASE AND FOREVER DISCHARGE the Released Parties from all liability to me, my personal representative, assigns, heirs and next of kin for injury, loss or damage arising out of my participation in Activity. This release extends to injury, loss or damage caused, in whole or in part, by the negligence of any of the Released Parties.

The Released Parties are: Channel Islands Bicycle Club, Leslie Ogden, Greg Jones, Lisa Jones, Foster Nagaoka, Linda Bott, the Pacific Coast Highway Randonneurs, Randonneurs USA, (RUSA), Audax Club Parisien, and Randonneurs Mondaux, their directors, officers, employees, volunteers, representatives, and agents, the event holders, event sponsors, event directors, and event volunteers; I AGREE NOT TO SUE the Released Parties for injury, death, loss or damage to me and/or my minor child(ren), my bicycle, or other property caused by or resulting from my participation, in any capacity, whether as a participant, volunteer, or otherwise, in Channel Islands Bicycle Club's 2012 Pacific Coast Highway Randonneurs Fleche.

This release extends to the Released Parties' agents, employees, personal representatives, heirs, next of kin, and all other persons acting on their behalf or in concert with them, from any and all claims and liability.

3. INDEMNITY AGREEMENT

I PROMISE AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASED PARTIES FROM ANY LOSS, INJURY, DAMAGE, CLAIM, JUDGMENT, OR EXPENSE, including legal fees and costs of defense, that Released Parties may incur arising out of my participation, in any capacity, whether as a participant, volunteer, or otherwise, in The Channel Islands Bicycle Club's 2012 Pacific Coast Highway Randonneurs Fleche.

4. MISCELLANEOUS

This voluntary Release, Assumption of Risk, and Indemnity Agreement is governed by California law and is intended to be as broad and inclusive as California law permits. If any portion of this agreement is held invalid, the balance shall continue in full force and effect.

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.

I have not signed this agreement in reliance on any representation or inducement of the Released Parties.

I HAVE READ ALL THREE (3) PAGES OF THIS DOCUMENT. I UNDERSTAND IT INCLUDES A RELEASE OF CLAIMS FOR INJURY OR DEATH TO ME OR MY CHILD(REN), AND FOR LOSS, THEFT OR DEATH OF, OR INJURY OR DAMAGE TO MY BICYCLE OR OTHER PROPERTY. I AM AWARE THAT THIS CONTRACT IS LEGALLY BINDING AND THAT I AM RELEASING LEGAL RIGHTS BY SIGNING IT.

Signature of Adult [Parent or Court-Appointed Legal Guardian of Minor(s)]:

Print Name:
Dated:
Signature: (after printing)
Names and ages of children:

Be sure to print the form before clicking the button!

(only your name will be added to the list)