DECEMBER 11, 2022

Race bib no.:

NAME:

ADDRESS:
AGE: GENDER:
CELLPHONE NUMBER:
BIKE GROUP

PERSON TO NOTIFY NAME:

INCASE OF CONTACT
EMERGENCY: NUMBER:

I certify that I am physically fit to participate in this event and have not been advised otherwise
by a Qualified medical practitioner/person.

I acknowledge that this 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 risk includes but not
limited to: actions of other people including, but not limited to, participants, volunteers,
spectators, coaches, event officials, and committees of the said event; lack of hydration, weather
and other natural conditions. I assume all the risks and accountability in any injury or damage to
property in participating in this event.

I hereby certify that I am mentally competent to enter into this waiver and I have given up future
legal rights to the organizers of this event and I have signed this WAIVER freely, voluntarily and
under no duress.

___________________________________ ________________________________
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
(Parent/Guardian)
For 18 years old and below only

Conforme: (by bike club representative if any)

___________________________________
SIGNATURE OVER PRINTED NAME