2000 AMERICAN CYCLING ASSOCIATION (ACA) ACCIDENT WAIVER AND RELEASE OF LIABILITY
2000 ONE-DAY MEMBERSHIP APPLICATION

EVENT NAME____________________________________________DATE(S)_________________________

I acknowledge that this athletic event is an extreme test of a person’s physical and mental limits and carries with it the potential for death, serious injury and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of athletes, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to athletes, but are also present for volunteers. I hereby assume all of the risks of participating and/or volunteering in this event. I realize that liability may arise from negligence of carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault. I certify that I am physically fit, have sufficiently trained for participation in the event and have not been advised otherwise by a qualified medical person that I can't compete/race. I acknowledge that this ACA Accident Waiver and Release of Liability form will be used by the event holder, sponsors, and organizers in events in which I may participate and that it will govern my actions and responsibilities at said events.

In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assign as follow: A) Waiver, Release and Discharge from any and all liability for my death disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to me or my traveling to and from this event, The American Cycling Association, its officers and members, the FOLLOWING ENTITIES OR PERSONS: Their directors, officers, employees, volunteers, representatives, and agents, the event holders, event sponsors, event directors, event volunteers, and event officials. B) Indemnify and hold harmless the entities or persons mentioned in the paragraph from any and all liabilities or claims made by other individuals or entities as a result of my or any actions during this event.

· I hereby consent to receive medical treatment, which my be deemed advisable in the event of injury, accident and/or illness during this event.

· I am aware that this event is not an event permitted by USA Cycling and that USA Cycling insurance does not apply.* I understand that at this event or related activities

· I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and/or assigns.

The ACA Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I hereby certify that I have read this document and I understand its contents.

NAME(print)____________________________________CLASS/CATEGORY ENTERING:______________

Address__________________________________________Club Name________________________________

CITY___________STATE_____ZIP___________Telephone#:______________(H)_____________(W)

E-mail Address:_______________________________________________________________

Emergency Contact: _________________________________Phone : __________________________

SIGNATURE OF ENTRANT:___________________________________________________________

ACA Club #:______ACA Membership #______RACING AGE:______

ONE DAYMEMBERSHIP(ck)______(Additional $2.00 Fee)

PARENT OR GUARDIAN FOR MINORS ( UNDER 18 YEARS OF AGE)

The undersigned parent and/or natural guardian or legal guardian does hereby represent that he/she is, in fact acting in such capacity and agrees to save and hold harmless and indemnify each and all of the parties refereed to above from all liability, loss, cost, claim or damage whatsoever which my be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.

Signature of Parent or Guardian of Minor________________________________Date _______________