Cowichan Valley Sue Wells Ride for ALS

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Team name   First name   Last name   Email address   Age at end of year after event 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Gender -- Male Female   Club name Choose one Duncan Just Me MIVA Other     Phone #   Address   Emergency contact name   Emergency phone #   Distance Choose one 45 km 90 km 160 km   Category Choose one Adult Masters Youth (0 - 17) Choose one Adult Masters Youth (0 - 17) Choose one Adult Masters Youth (0 - 17)   Event entry fee TBD

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Please review the waiver provided by the event organizer and click the check box below to accept it. Print waiver WAIVER IN CONSIDERATION of my participation in this organized ride, I, myself, my heirs, executors, administrators, successors, assigns, assumes all risks and dangers and DO HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE Cycle Therapy Bikes, Red Arrow Brewing Company, Just Jakes Restaurant, The Corporation of the District of North Cowichan, South Cowichan, The Cowichan Valley Regional District, the City of Duncan, local charities, volunteers, sanctioning bodies and sponsoring companies and all of their respective agents, officials, officers, directors, partners, employees, shareholders, association members, servants, contractors, representatives, elected and appointed officials, successors, assigns, heirs, executors, and administrators where applicable OF AND FROM ALL claims, demands, damages, costs, expenses, actions, causes of actions, suits, depts.., duties, accounts, bonds, warranties, indemnities, claims over, contract and liabilities, whether in law or equity, in respect of death, injury, loss or damage to my person or property HOWSOEVER CAUSED, arising or which may arise by reason of my participation in said event, whether AND NOTWITHSTANDING that the same may have been caused by or contributed to or occasioned by negligence of the aforesaid. I FURTHER UNDERTAKE to HOLD AND SAVE HARMLESS AND AGREE TO INDEMNIFY all of the aforesaid from and against any and all liability incurred by any or all of them arising as a result of, or in any way connected with my participation in the said event. BY SUBMITTING THIS ENTRY, I ACKNOWLEDGE HAVING READ, UNDERSTOOD AND AGREED to the above WAIVER, RELEASE AND INDEMNITY. I WARRANT that I am physically fit to participate in this event and that I am 18 years of age or older or that I am the parent or legal guardian or a sanctioned representative of the parent or legal guardian of this participant under the age of 18. __________________________________________ Print Your Name Here __________________________________________ ____________________ Sign Your Name Here Today’s Date __________________________________________ Sign Here on behalf of Children Under 18 years old I accept the terms of the waiver Name of parent or guardian who approves this activity Please enter your name here