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For Bike
CHECK NUMBER: ______________ AMOUNT: $________________ STAFF VOLUNTEER VENDOR
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2006 Bike
1.
Print Form (one copy per person) 2.. Complete Form 3. Sign Waiver 4. Mail with Correct Payment (check or credit
card – Visa and MasterCard only)
Name: ____________________________________________
Address: ___________________________________________
City:
Male Female Age: ______________
(age required for
under age 18 registrations)
Home Phone: (_________) _____________________________
(area code)
Other Phone: (_________) _____________________________
(area code) cell work
other
E-mail: _____________________________________________
EMERGENCY CONTACT
Name:
______________________________________________
At event Not at event
Emergency Phone (_________)
_____________________________
(area code) cell work
other
REGISTRATION FEES (including a late fee of $25 after january 15, 2006)
$235 - Adult Cyclist
(week-long option)
Two 4-day
options (150 spaces for 4-day options available on first come first serve
basis)
$210 (Palatka –
($215 by Visa or MasterCard)
$110
- Child Cyclist (under 16 at
time of event)
(Children under 12 must be on
a tandem or trailer bike)
$125
- Non-Rider (see details on web site)
($130 by Visa or MasterCard)
PAYMENT TOTAL
FEES
$________
Check
Credit Card ________________ ________________________________ _________
Type (Visa & MasterCard only) Credit card number Exp. date
COMPLIMENTARY
T-SHIRT (Check size; if
no size is indicated, you will receive a Large)
Small Medium
Large
X-Large
XX-Large
TYPE OF BIKE
Single
Tandem Recumbent
Tandem Recumbent
Bike with Trailer
Non-Rider
AIRPORT SHUTTLE
NEEDED (Please
check Yes or No. Shuttle will be
provided from
Yes No
VOLUNTEERS
A partial to full fee waiver is possible for volunteering your
services. However, registration fees are
due with this form; fees are refunded AFTER the event. If selected, you will be contacted with
further instructions. Bike
Rest stops
Registration
Headquarters Sag support/driver(Must have own vehicle)
Please list your experience/credentials
(RN, MD, EMT, Law Enforcement, rides worked, etc.) if applicable.
__________________________________________________________________
SAFETY
EDUCATION (optional, but we would appreciate this information):
I have taken a Road I or Effective Cycling Class
I am already a League of American Bicyclists Certified
Instructor
LCI #_______________ or ECI #
________________
I am interested in taking a “Rolling” Road I Course on Bike Florida 2006
(more information about signing up will be
provided with the meal and options order form in January; to learn more about
the class check the website
of the League
of American Bicyclists at www.bikeleague.org/insructors/courses.cfm#FL)
HIPPA COMPLIANCE
In consideration with HIPPA, I
authorize the release of my medical information to the medical staff of Bike
WAIVER
(Your
registration will NOT be processed unless this waiver
is signed and dated prior to participation.)
In consideration of being allowed to
participate in any way in the Bike Florida 2006 event, related events and
activities, the undersigned appreciates and acknowledges that: (1) The risk of
injury from the activities involved in this program is significant, including
the potential for permanent paralysis, death, and while particular rules,
equipment and personal discipline may reduce this risk, the risk of serious
injury does exist; and, (2) I knowingly and freely assume all such risks, both
known and unknown, and assume full responsibility for my participation; and,
(3) I willingly agree to comply with the stated and customary terms and
conditions for participation. If, however, I observe any unusual
significant hazard during my presence or participation, I will remove myself
from participation and bring such to the attention of the nearest official
immediately; and, (4) I, for myself and on the behalf of my heirs, assigns,
personal representatives and next of kin, hereby release and hold harmless BIKE
FLORIDA, INC., their officers, officials, agents and/or employees, volunteers,
staff, other participants, sponsoring agencies, sponsors, advertisers, and if
applicable, owners and lessors of premises used to conduct the event
("Releasees"), with respect to any and all injury, disability, death
or loss or damage to person or property. I have read this release of liability
and assumption of risk agreement, fully understand its terms, understand that I
have given up substantial rights by signing it, and sign it freely and
voluntarily without any inducement.
X
_________________________________________________
Participant Must Sign Waiver
X __________________________________________________
Printed Name of Participant
Date:________________________________________________
Must be Dated Prior to Participating
For
Participants of Minority Age (Under Age 18 at Time of Registration):
This is to certify that I, as parent/guardian with legal responsibility for
this participant, do consent and agree to his/her release as provided above all
the Releasees, and for myself, my heirs, assigns, and next of kin, I release
and agree to indemnify and hold harmless the Releasees from any and all
responsibilities incident to my minor child's involvement or participation in
these programs as provided above.
X
__________________________________________________
Parent/Guardian's
Signature
X___________________________________________________
Printed Name of
Parent/Guardian
X___________________________________________________
Printed Name of Child
Date:________________________________________________
Must
be Dated Prior to Participating
EVERYONE ATTENDING BIKE
vendors please contact us for instructions.
REFUND POLICY
A $35 processing fee will be charged on all refunds. Refund
requests MUST be in writing, stating reasons for refunds such as medical and
emergencies. No refunds will be
processed after February 17, 2006. There
will be no exceptions. Event will take place rain or shine. We are
not responsible for acts of God.
PRINT COMPLETED FORM, SIGN & DATE
WAIVER. ADDRESS ENVELOPE AND MAKE CHECK
OR MONEY ORDER (IN
Note: Additional postage may be required to mail two entries in same envelope.
To confirm your entry, a list of registered
cyclists will be posted on the website with rider number.