PADYAKAN SA SAIPAN 21

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Team name   First name   Last name   Email address   Date of birth DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    MM 01 02 03 04 05 06 07 08 09 10 11 12       YYYY 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922    Gender -- Male Female   Phone #   Address   Emergency contact name   Emergency phone #   Distance Choose one BEGINNERS COURSE (20KM) LONG COURSE - MTB (60KM) LONG COURSE - ROAD (60KM)   Category Choose one MTB (BEGINNERS COURSE) ROAD (BEGINNERS COURSE) Choose one 19 UNDER 20 ^ 29 30 ^ 39 40 ^ 49 50 ^ 59 60 UP OPEN DIVISION Choose one 19 UNDER 20 ^ 29 30 ^ 39 40 ^ 49 50 ^ 59 60 UP OPEN DIVISION

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Please review the waiver provided by the event organizer and click the check box below to accept it. Print waiver WARNING: READ CAREFULLY. THIS AGREEMENT INCLUDES A RELEASE OF LIABILITY AND WAIVER OF LEGAL RIGHTS AND DEPRIVES YOU OF THE RIGHT TO SUE EMON MASONIC LODGE NO. 179 AND OTHER PARTIES. DO NOT SIGN THIS AGREEMENT UNLESS YOU HAVE READ IT IN ITS ENTIRETY. SEEK THE ADVICE OF LEGAL COUNSEL IF YOU ARE UNSURE OF ITS EFFECT. WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT In consideration of acceptance of this application, I hereby waive, release and discharge any and all claims for damage, death, personal injury and/or property damage which I may have, of which may accrue to me as a result of my participation in bike racing or competitions. The release is intended to discharge in advance the promoters, the sponsors, promoting clubs, officials and any involved village, municipality, government agency, or other public entities (and their respective agents and employees) from and against any and all liability arising out of or connected in any way with my participation in the bike race, ride or competition, even though liability may arise out of negligence or carelessness on the part of the person or entities mentioned above. I further understand that serious accidents occasionally occur during rides or race competitions and the participants in bicycle rides or competitions occasionally sustain moral or personal injuries and/or property damage as a consequence thereof. Knowing the risks of bicycle rides and competitions, nevertheless, I hereby agree to assume the risks and to release all of the persons or entities mentioned above whom through negligence or carelessness might otherwise be liable to me (heirs or assignees) for damages. It is further understood and agreed that this waiver, release and assumption of risks are to be binding on my heirs or assignees. I also permit my name, photo and interview to be used by the media , sponsors and promoters. I accept the terms of the waiver Name of parent or guardian who approves this activity Please enter your name here