RUSA Dart NE 2008

Berkshire Brevet 2008 Registration Form

 

For Tandem participants, list the names and ages of both riders in one space.

 

 

 

 

 

 

TEAM NAME:____________________________________________________________

 

 

 

TEAM CAPTAIN (CYCLE#1)

 

 

 

 Name___________________________________________________________Age:______

 

 

 

RUSA Member #____________________

 

 

 

Phone:____________________________

 

 

 

Address_______________________________________________________________

 

                                                (Street)

 

 

 

           _________________________________________________________________

 

                (City)                                      (State)                          (Zip)

 

 

 

Club Affiliation_____________________________________

 

 

 

E-Mail Address____________________________________

 

 

 

 

 

CYCLE#2

 

 

Name:___________________________________________________________Age:______

 

 

 

RUSA Member#________________________

 

 

 

CYCLE#3

 

 

Name:___________________________________________________________Age:______

 

 

 

RUSA Member#________________________

 

 

 

CYCLE#4 (optional)

 

 

 

Name:___________________________________________________________Age:______

 

 

 

RUSA Member#________________________  

 

CYCLE#5 (optional)

 

 

 

Name:___________________________________________________________Age:______

 

 

 

RUSA Member#________________________

 

 

 

 

 

 

 

 

 

 

 

PROPOSED TIMETABLE (you must have a departure control point, a 10-hour control and a 12-hour control; there is no limit to the number of controls)

 

 

Departure_____________________________________ Starting date and time______________

 

 

 

Control #1_____________________________________Start time +______hours

 

 

 

Control #2 ____________________________________ Start time +_____ hours

 

 

 

Control #3_____________________________________Start time +______hours

 

 

 

Control #4_____________________________________Start time +______hours

 

 

 

Control #5_____________________________________Start time +______hours

 

 

 

Control #6_____________________________________Start time +______hours

 

 

 

Control #7_____________________________________Start time +______hours

 

 

 

Control #8_____________________________________Start time +______hours

 

     

 

Estimate mileage at 12-hour point__________________

 

 

 

 

 

[   ] RUSA Dart New England entry fee ($30 per Team)

 

  

 

[   ] copies of maps and cues, Destination Westfield, MA

 

 

 

Pre-Registration Only, Deadline August 3

 

 

 

 

 

Please enclose a check in the correct amount made out to "New Horizons Sports" and return this form , the signed waiver, and check to:              

 

Dart NE/New Horizons Sports, 55 Franklin St., Westfield, Ma 01085

 

 

 

 

 

League of American Wheelmen ("LAW") Release and Waiver of Liability, Assumption of Risk, and Indemnity and Parental Consent Agreement ("Agreement")

 

IN CONSIDERATION of being permitted to participate in any way in the Northeast Sport Cyclists ("NSC") Berkshire Brevets sponsored Bicycling Activities ("Activity") I, for myself, my personal representatives, assigns, heirs, and next of kin:

 

1. ACKNOWLEDGE, agree and represent that I understand the nature of Bicycling Activities and that I am

qualified, in good health, and in proper physical condition to participate in such Activity. I further acknowledge that the Activity will be conducted over public roads and facilities open to the public during the Activity and upon which the hazards of traveling are to be expected. I further agree and warrant that if at any time I believe the conditions to be unsafe, I will immediately discontinue further participation in the activity.

 

2. FULLY UNDERSTAND that: (a) BICYCLING ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW;  (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily forseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation in the Activity.

 

3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the NSC, the LAW, the Berkshire Brevets, RUSA,  Boston - Montreal - Boston, New Horizons Sports, their respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises on which the Activity takes place, (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNIFY AGREEMENT, I, or anyone on my behalf, makes a claim against any of the releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which may incur as a result of such claim.

 

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

 

PARTICIPANT

SIGNATURE

(if over age 17):_____________________________________________________Date:____________________ 

 

AND I, THE MINOR'S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF BICYCLING ACTIVITIES AND THE MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, AND DAMAGES ON THE MINOR'S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE, I, OR THE MINOR, OR ANYONE ON THE MINOR'S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.

 

PRINTED NAME OF

PARENT/GUARDIAN:________________________________________________Date:________________

 

PARENT/GUARDIAN SIGNATURE

(if participant is under the age of 18):_________________________________________________________