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Northwest Tandem Rally Registration Form |
Captain:
____________________________ Address:
______________________
Last Name First
Name
MI
_______________________
City
State Zip Code
Daytime phone: ________________ Evening phone:
____________________
E-mail address:__________________________
Emergency Contact Name and Phone: _________________________________
Stoker:
____________________________ Address:
_______________________
Last Name First
Name
MI
_______________________
City
State Zip Code
Daytime phone: ________________ Evening phone:
____________________
E-mail address:__________________________
Emergency Contact Name and Phone: _________________________________
Child #1: __________________________
Single Rider #1: _____________________
Child #2: __________________________ Single
Rider #2: _____________________
Child #3: __________________________ Single
Rider #3: _____________________
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ORDER FORM |
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REGISTRATION FEES |
BANQUET MEALS |
| CLOTHING ORDERS T-Shirts (order must be received by June 1, 2003) Adult Short Sleeves - $10.00 __S __M __L __XL __XXL Children's Short Sleeves - $8.00 __S __M __L __XL __XXL Adult Long Sleeves - $15.00 __S __M __L __XL __XXL TOTAL for T-Shirts $_________ Jerseys (order must be received by May 1, 2003) Adult Sizes Only - $60.00 __S __M __L __XL __XXL TOTAL for Jerseys $_________ |
TOTAL COSTS
Total Registration Fees $__________ Total Meal Charges $__________ Total T-Shirt Charges $__________ Total Jersey Charges $__________ GRAND TOTAL $__________ |
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In consideration of the acceptance of this entry and by signing this release for myself (or for named entrant, if entrant is under age 18), I waive any and all claims for myself and my heirs against NWTR 2003, all organizers and volunteers of the NWTR 2003, the Eugene Hilton Hotel, all sponsors, their officers and members, all municipalities and counties in which the NWTR 2003 participates, officials, volunteers and their representatives and successors and all of the above officers, directors, employees and agents, from all claim of liabilities of any kind arising out of my participation in this event, including damage or loss to my person and property which may be caused by any act or negligent act, or failure to act, by the above persons or entities or any injury, harm, inconvenience, foreseen or unforeseen, suffered as a direct result of my participation in the NWTR 2003 or in any activity associated with it. I grant permission to any and all of the foregoing to free use of my name, voice, or likeness in any broadcast, telecast, advertising or promotion related to this event or future Northwest Tandem Rallies. I further state that I am in proper physical condition to participate in this event. I understand that participation in the NWTR 2003 is a potentially hazardous event. I will not participate in the NWTR 2003 unless I am medically able to do so and I am properly trained. I agree to assume all risks associated with the participation in this event, including without limitations, falls, contract with other participants, adverse weather conditions, adverse road conditions, traffic, contact with motor vehicles, camping, participating in events associated with the NWTR 2003, and damage or loss of my bicycle or other equipment, all such risks being understood and appreciated by me. I assume the risk of all dangerous conditions during the NWTR 2003 and waive any and all specific notice of the existence of such conditions, and will assume and pay my own medical and emergency expenses in the event of an accident, illness, or other incapacities regardless of whether I have authorized such expenses. I warrant that I am a sufficiently competent cyclist to handle the road conditions found on the NWTR 2003 and my bicycle is in safe condition. I also understand wearing a helmet can minimize head injuries which may occur in a cycling accident and that NWTR 2003 requires ALL riders to wear ANSI approved helmets and carry a supply of water. I agree to obey the rules of the road under Oregon State law. I understand and waive my rights to continue participation in the NWTR 2003 at any time officials of the event find me in violation of the above requirements. Captain’s Signature (or Single rider) ________________________ Age ______ Stoker’s Signature _________________________ Age ______
Parent or Guardian’s Signature _________________________
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| Please make checks payable
to: NWTR 2003 Mail to: NWTR 2003 Remember - registration PO Box 11044 must be received by June 1 Eugene, Oregon 97440 to avoid late fees |
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