Registration, Waiver and Release Form

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