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Official 2010 dogwood 100 Registration Form April 24, 2010 Name:
_______________________________ email: _________________________________ Address:
ONLY PRE-REGISTRATION BY April 16th GUARANTEE’S A
T-SHIRT T-Shirt
Size: S [ ] M [
] L [ ] XL [
] XXL [ ] Courses:
100-Mile [ ] 62-Mile [ ] 35-Mile [ ]
10-Mile [ ] Pre-Registration (BY MAY 16th)
- $30 After
May 16th and ride day registration - $35 Children
11 and under ride free (A $5.00 fee will be charged if eating lunch.) Make
checks payable to: United Way Dogwood
100 Mail
to: United Way Dogwood 100 SORRY,
NO REFUNDS Please print
clearly One form per rider To
participate in the Dogwood 100, the following must be read and signed in blue
ink below. Release and Waiver
Statement: In consideration of the
acceptance of my entry, I the undersigned participant, for myself, my family
members, heirs, administrators, personal representatives, successors, and
assigns herby fully release, discharge and hold harmless any sponsors,
owners, and operators of motor vehicles and officers, directors, employees,
volunteers, and lessors of any of the foregoing
persons or entities from any and all liability, whether resulting from
negligence of any aspect of the Dogwood 100, whether a pre-ride, post-ride
activity or the ride itself. I also
expressly covenant with the aforementioned persons and entities not to sue
any such persons and entities for any such activity, including the negligence
of any such persons or entities. I
certify and represent by my application for entry that my physical condition
is adequate to participate safely in the Dogwood 100, and I herby acknowledge
that the above persons and entities have no obligation to provide medical
care and have not undertaken the responsibility to do so. In the event that I receive medical care as
a result of a medical emergency, I herby consent to such care and fully
release the person(s) providing such care from any and all liability, whether
resulting from negligence or otherwise.
I authorize and consent to volunteers or to persons employed or contracted
by Dogwood 100 to use any videotape,
film, newsprint, written advertisement, or otherwise, or any materials
containing my name or picture. I
further release any sponsors and all persons acting under authority from any
claims I might have due to initial or subsequent publication of such
materials or photographs. I herby
certify that I have fully read and understand the foregoing release, waiver
and covenant not to sue, and sign it voluntarily. I also agree to abide by all traffic laws
and to wear a helmet at all times during the ride. Signature:
_____________________________________________ Date:____________ Parent/Guardian (if rider is a
minor):____________________________Date:____________ |
