Cops Cycling for Survivors is an annual group bicycle ride. It consists of police officers, family and friends of law enforcement officers who have given their lives in the line of duty. The participants bicycle nearly 1,000 miles around the perimeter of Indiana to support survivors of police officers killed in the line of duty. On average the cyclists ride 7-8 hours and 75 miles per day. Cyclists should have a well-maintained road bicycle. The ride will take place from July 10-22, 2017. Except for day 1 the maximum number of riders per day is 30 with police and survivors being given first consideration. Cyclists can ride any number of days, partial days or every day.
To register, check the appropriate boxes below for the days you plan to ride and complete the required information. Registration forms are due June 16, 2017.
This application must be accompanied by a $50.00 registration fee paid to Cops Cycling for Survivors. Your registration fee covers a participant t-shirt, a Cops Cycling jersey, most meals and all housing during the duration of your participation in the ride. All participants are required to wear the Cops Cycling jersey every day of participation. The only jerseys authorized for wear are those purchased in 2013 and after or the jersey received for registration this year. There will be designated committee members assigned to laundry detail each afternoon/evening.
All cyclists must raise a minimum of $75.00 per day or partial day. All donations are due by July 1, 2017. See website or sponsor form for donation details.
July 10 11 12 13 14 15 16 17 18 19 20 21 22
Miles 55 85 84 68 77 65 100 87 38 88 45 85 69
I wish to participate as a RIDER SUPPORT
Will you be cycling a partial day(s)? If so, please provide the date and location you will start and where you will end in the field at the bottom of page 2 on this form. Cops Cycling does not provide transportation.**
Full Name: Age: Blood Type:
Address: City: State: Zip:
Home Phone: Work Phone: Cell Phone:
Email Address: Dept., Agency, or Survivor of:
Health Insurance: ID#: Group #:
Emergency Contact: Full Name: Relationship:
Home Address: City: State: Zip:
Work Name: Address:
City: State: Zip:
Home Phone: Work Phone: Cell Phone:
T-shirt size: Small Medium Large XL 2XL 3XL 4XL
Jersey Options – USA Sizes:
Women’s short sleeve: Small Medium Large XL 2XL 3XL
Men’s short sleeve: Small Medium Large XL 2XL 3XL
Sleeveless (men’s cut only): Small Medium Large XL 2XL 3XL
Additional Jersey Order ($78.00 each):
Agreement, Waiver and Indemnifications
In consideration of the acceptance of my application for registration to participate in Cops Cycling for Survivors Foundation, Inc.’s annual cycling event, I hereby freely agree to the following:
I acknowledge that overnight accommodations and other locations utilized during the ride have varying rules of use and behavior. As a participant in this ride, I understand that I represent Cops Cycling for Survivors Foundation, Inc. and will abide by all instructions provided by the Cops Cycling for Survivor Foundation’s President (or designee) or face immediate removal from the event. I will observe all traffic laws, wear a helmet and adhere to all other event safety rules, some of which can be found on the website. Cops Cycling for Survivors Foundation does not arrange transportation for cyclists participating in this event other than to group dinners or survivor gatherings away from overnight accommodations
While cycling is a great recreational sport, I understand that it is an inherently risky and dangerous activity, and that it is my responsibility to continually ride and otherwise participate so as to neither endanger myself nor others. I accept responsibility for the condition and adequacy of my equipment, any equipment provided for my use, road and weather conditions and my actions. I understand and acknowledge that participating in this cycling event may expose me to dangers from both known and unanticipated risks. Examples of some of the dangers associated with cycling include dangers arising from (i) collisions with vehicles, other riders, pedestrians or other fixed or moving objects, and (ii) surface hazards, including pot holes, (iii) equipment failures, (iv) inadequate safety equipment, and (v) the acts of other people including other riders and event volunteers. For myself, my heirs, my executors and administrators, I fully assume all risks associated with participation in the event, and I waive, release and discharge, and agree to hold harmless and indemnify, all sponsors, organizers, coordinating police departments, Cops Cycling for Survivors Foundation, Inc., and its officers, volunteers, and board and committee members (collectively, the “Releasees”), from or related to any and all injuries, claims or damages (whether to me or to others) arising from my participation in this event.
I attest and verify that I am physically fit, am an experienced cyclist, have sufficiently trained for the event, and my physical condition has been verified by a licensed medical doctor or, if not verified, I have good reason to believe I am sufficiently fit to participate in the event. I grant full permission to any and all of the foregoing to use my likeness for any legitimate purpose whatsoever. Those under 18 who desire to participate must have the participant’s acknowledgment accompanied by the signature of a parent or guardian. If electronically submitted, your typed name inserted is considered equal to a signature.
I accept this Agreement, Waiver and Indemnification, and acknowledge that I understand its consequences.
Participant Signature: Date:
I am signing this Agreement, Waiver and Indemnification on behalf of a minor child over which I am a parent/guardian. Further, I agree to hold harmless and indemnify the Releasees from any claims that I, my child or another may allege against the Releasees from or relating to any and all injuries, claims or damages that may arise as a result of the minor’s participation in this event. If electronically submitted, your typed name inserted is considered equal to a signature.
Parent/Guardian Signature: Date:
**Type details for partial day cycling in the field. If you need to know tentative stop locations, call Rich Crawford at 317-650-8961.