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For Bike Florida office use only: RIDER # _____________ DATE RECEIVED: _____________________

CHECK NUMBER: ______________ AMOUNT: $_______________ _ STAFF VOLUNTEER VENDOR
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2006 Bike Florida Registration Form: 1. Sign Waiver 2. Mail to P.O. Box 5295 , Gainesville, FL 32627 

HIPPA COMPLIANCE: In consideration with HIPPA, I authorize the release of my medical information to the medical staff of Bike Florida during the week of and the week following the 2006 bicycle event.

                                             
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