ENTER RIDER INFORMATION

First Name

Last Name

Address

City

State

ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMOMSMTNCNDNENVNHNJNMNYOHOKORPARISCSDTNTXUTVAVTWAWIWIWY

Zip Code

Phone

E-mail Address

Age

RUSA#

Sex

MaleFemale

EMERGENCY CONTACT INFORMATION

Full Name

Phone

EVENT INFORMATION
(Select all of the Events you intend to ride)

			300K ACP Brevet - Jul 10, 2010
			400K ACP Brevet - Aug 28, 2010
			1000K ACP Brevet - Sep 23, 2010
			600K RUSA Brevet - Sep 24, 2010
			250K RUSA Brevet - Oct 23, 2010
			200K RUSA Brevet - Nov 27, 2010

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RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT ("AGREEMENT")

IN CONSIDERATION of being permitted to participate in any way in the Harpeth Bicycle Club (“Club”) 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 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 NEIGLIGENCE OF THE “RELEASEES” NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL 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 Club, the LEAGUE OF AMERICAN WHEELMEN d/b/a LEAGUE OF AMERICAN BICYCLISTS, RANDONNEURS USA, AUDAX CLUB PARISIEN, RANDONNEURS MONDIAUX, their respective administrators, directors, agents, officers, members, volunteers, and employees, other participants, and 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 the RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY 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 any my incur as the result of such claim. 4. HEREBY CONSENT to receive medical treatment, which may be deemed advisable in the event of injury, accident and or illness during this Activity. 5. HEREBY CONSENT to allow my photo, video or film likeness taken during the Activity to be used for any legitimate purpose by the Club, producers, sponsors, organizers and or any other assigns. I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTAINTIAL 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 ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THE AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

No Yes	I have read and understand the above Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement ("Agreement"). I also understand that I will be required to sign this Agreement the morning of the Event.
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