Ride the Rockies for
Epilepsy
Registration, Waiver and
Release Form
(PLEASE PRINT
CLEARLY)
First
Name ________________________ Initial _____ Last Name
_________________________
Address
____________________________________________________ City
________________
Province
________________ Postal Code ________________
Email
(for important Ride updates)
___________________________________________________
Home
Phone ______________________ Other Phone _________________________
Date
of Birth (must be 20 years or older) _____________________________
Sex F M
(Please circle all applicable answers)
Do
you have epilepsy? Yes No
If yes, is it under control and
seizure free? Yes No
Are
you a friend or family member of a person with epilepsy? Yes
No
Where
did you hear about the ride?
____________________________________________
In
order to receive important Ride information including event updates,
training and fund raising tips, and information, you need to include
your email address. You may withdraw your consent for email updates
at any time.
Are you willing
to share your contact information with fellow participants? Yes
No
If
you mark “yes,” your information will only be shared with
other registrants of the RIDE for the purpose of Training Rides,
invitations, and other official event reasons. Your contact
information will not be used for any other reasons. Please read our
complete Privacy Policy located on the index of this
blog.
In
the event you have epilepsy and needs to stop during the day
while on the RIDE for any reason, there will always be someone who stops with you
until such time you are able to continue riding that day.
For
data storage purposes all personal information is kept offline at
lest for the 2015 year. You will be notified prior to any change.
WAIVER
AND RELEASE OF LIABILITY
(Please
read and sign below.)
I
wish to participate in Ride The Rockies For Epilepsy
benefiting the Seizure Monitoring Unit of Foothills Hospital,
Epilepsy Program of the Clinic Neuroscience, University of Calgary,
scheduled to take place in July 6 - 31, 2015,
as well as various pre- and post-event activities (including, without
limitation, one or more training rides) (the “RIDE”) and I agree
to abide by all rules, regulations, and event instructions of the
RIDE, as well as all applicable municipal and provincial laws and
regulations.
I
understand that participating in such a RIDE, using public streets
and facilities, and the use of and participation in services made
available to participants during the RIDE (that may include massage,
chiropractic, and medical services) is a potentially hazardous
activity and can result in serious personal injury or death. I am
aware of and expressly assume all risks associated with participating
in this RIDE, including, without limitation, falls, contact with
other participants, objects, bicycles and vehicles, the effects of
weather, traffic, and the conditions of the streets and routes used
by the RIDE, and I assert that my participation in this RIDE is
voluntary.
In
consideration for being permitted to participate in this RIDE, I, for
myself and for anyone entitled to act on my behalf, hereby waive and
release, from any and all claims for injuries and damages I may have
arising out of the RIDE or my participation in the RIDE, Ride the
Rockies for Epilepsy, the Epilepsy Program, Clinic
Neuroscience. University of Calgary, any beneficiaries, sponsors,
officials, participating clubs, communities, organizations, friends
of the RIDE, Riders, Crew Members, consultants, participants,
third-party vendors, government or public entities (including,
without limitation, any towns municipalities, Departments of
Transportation), and each of their respective affiliates, successors,
officers, directors, employees, volunteers, agents, and
representatives, including, without limitation, the RIDE medical
sponsor, medical director, and members of the medical team.
I
intend by this Waiver and Release, in advance, to waive my rights, to
covenant not to sue to release for future claims, and to discharge
all of the persons and entities mentioned above, from any and all
loss or damage, including, but not limited to claims for damages for
death, personal injury or property damage that I may have, or which
may hereafter accrue to me, as a result of my participation in all or
any portion of this RIDE, even though that liability may arise from
active or passive negligence, carelessness, or recklessness (whether
simple or gross) on the part of the persons or entities being
released, from dangerous or defective property or equipment owned,
maintained, or controlled by them or because of their possible
liability without fault.
I
understand and agree that this Waiver and Release is binding on my
heirs, assigns, and legal representatives.
I
attest that I am physically capable of, and have sufficiently trained
for, completing each respective element of this RIDE. If I am
aware of or under treatment for any physical infirmity, disorder,
ailment, or illness, my medical care provider has been apprised of,
and has approved of, my participation in this RIDE. I acknowledge
that I, and I alone, am solely responsible for my personal health and
safety, and the personal property I bring with me. I consent to
receive medical treatment which may be advisable in the event of
illness or injuries suffered by me during this Ride, and I agree to
pay for the costs of any such medical treatment.
I
agree that my participation in the RIDE is subject to the sole
discretion of the organizers of the RIDE, and that my participation
may be limited or terminated, with or without cause.
I
represent and warrant that I will be at least 20 years old at the
time of the RIDE.
I
understand that all donations are for non-profit and non-transferable, even if I do not
participate in the Event. I further understand that my registration
fee is non-refundable, non-transferable, does not apply toward my
fund-raising commitment, and is not tax deductible.
RIDE
THE ROCKIES FOR EPILEPSY REGISTRATION
THIS IS NOT A REGISTERED CHARITY - March 2015
As
a Rider, I understand registration for this Ride is $100.00 so that I
can take part. If I am fund-raising to pay this amount
and it is not raised before June 31, 2015, I may make my own donation
to reach that minimum in order to ride.
I
give permission to Ride The Rockies for Epilepsy and each of their
respective affiliates, subsidiaries and agents, for the free use of
my name, photograph, voice, or likeness, in any broadcast, telecast,
advertising promotion, or other account of this Event or marketing or
promotion for future or similar events, and waive any rights of
privacy I may have in that regard, and I understand and consent that
I will periodically be receiving communications related to my
participation in the RIDE.
THIS
WAIVER AND RELEASE SHALL BE INTERPRETED AND THE RIGHTS OF THE PARTIES
DETERMINED UNDER THE LAWS OF THE PROVINCE OF ALBERTA AND BRITISH
COLUMBIA. THE ALBERTA AND BRITISH COLUMBIA COURTS SHALL HAVE
EXCLUSIVE JURISDICTION FOR ANY DISPUTE ARISING UNDER, OR PERTAINING
TO, THIS WAIVER AND RELEASE.
I
have carefully read this Waiver and Release and fully understand its
contents. I am aware that this is a release of liability and a
binding contract between myself and the persons and entities
mentioned above, and I sign it of my own free will. I understand that
I am giving up substantial rights, including my right to sue. I
acknowledge that I am signing this Waiver and Release freely and
voluntarily, and intend by my signature to be a complete and
unconditional release of all liability to the greatest extent allowed
by law.
Please
PRINT first and last name here
_______________________________________________________________
Signature
of participant
______________________________________________________________________
Date
_________________________________
Once you have completed this Registration, Waiver and Release form you must email the Ride for further directions to complete your registration to: CycleTheCndRockies@gmail.com
In
2012, Cam Keith’s life changed dramatically when he was diagnosed with
Epilepsy. Unable to get the seizures under control with medication Cam
lost his driver’s license and was unable to hold a job. 
