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NORTHBROOK BICYCLE CLUB & NORTHBROOK CYCLE COMMITTEE To: Northbrook Bicycle Club, Inc., Northbrook Cycle Committee, Northbrook Park District, and all Sponsors: Please accept my entry in the Save the Drome Cross Madness on November 23, 2003. I shall pay my entry fee for each race I enter. I hereby acknowledge that cyclo cross racing, steeple cross, and dirty double cross racing are dangerous sports and I hereby accept all the risks of the sport by entering this event. NOW THEREFORE: In consideration for allowing me to enter this event and as a condition of my voluntary participation in this event, I hereby waive, release, and discharge any and all claims for damages to person or property, death, or personal injury which I may have or hereafter may accrue to me as a result of my participation in the Save the Drome Cross Madness Races. This release is intended to discharge in advance the promoters and sponsors, including but not limited to the Northbrook Park District, the Northbrook Bicycle Club, Inc., the Northbrook Cycle Committee, all officials and any municipalities or other public entities (and their respective agents and employees), other individuals, corporations or entities in any way involved in this competition, and all physical trainers and or medical assistants, and any paramedic units or workers from and against any and all liabilities arising out of or connected in any way with my participation in the above designated event on the part of any of the persons or entities mentioned herein above. It is further understood and agreed that this waiver, release and assumption of risk is binding on my agents, heirs, representatives, executors, administrators and assigns.
Racer's Name: _____________________________________________ Date :___________________ Male Female (Circle one) Phone #:___________________________________________________ Complete Address: __________________________________________________________________ Date of Birth:__________________________ Racing Age (as of 12/31/03!!!!):__________________ USCF # (if applicable):______________________ Club:____________________________________ E-mail address:______________________________________________________________________ PARENT OR LEGAL GUARDIAN MUST SIGN IF RIDER IS UNDER 18 YEARS OF AGE.
NO UNSIGNED ENTRY FORM WILL BE ACCEPTED. *Signature of Entrant (or Parent/or Legal Guardian for minor entrant): *Sign Here: ____________________________________________ Date:_____________________ Print Name:_________________________________________________________________________ Emergency Contact/Phone #: __________________________________________________________
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