2017 Cow Creek Country Classic Entry Form

Name:______DOB: ______

Address:______

City:______State:______Zip:______

Email:______Telephone: ______

Did you ride last year? YES [ ] NO [ ]Referral Source: ______

ALL RIDERS $35.00 AFTER JUNE 11th 2017

MAIL TO: P.O. BOX 2920, WAXAHACHIE, TX. 75168

Individual Rider(s):______@ $30.00$______

Tandem Rider(s): $20.00 each______@ $20.00$______

Family Rider(s): $20.00 each 4 or more______@ $20.00$______

Corporate Rider(s): $25.00 8 or more______@ $25.00$______

I Plan to Ride: 10 [ ] 20 [ ] 38 [ ] 46 [ ] 77 [ ] 100 [ ]

T-Shirt Size: Small [ ] Medium [ ] Large [ ] X-Large [ ] XXL [ ]

Paid:$30.00Check/Cash/Credit Card:Visa [ ] MCard [ ] 3 Digit Pin [ ]

Card #:______Expiration:______

THIS ENTRY BLANK AND RELEASE FORM IS A CONTRACT WITH LEGAL CONSEQUENCES.

In consideration of the acceptance of my application for entry in the Cow Creek Country Classic, I hereby freely agree to make the following contractual representations and agreements.

I fully realize the danger of participating in a bicycle ride and will assume the risks associated with such participation, including, by way of example and not limitations, the following danger of collision with pedestrians, vehicles, other riders and fixed or moving objects; the dangers arising from surface hazards, and weather conditions; the danger of cycling on highly traveled roads and highways where vehicles travel at a high rate of speed; the failure to keep proper lookout, and the possibility of serious physical and/or mental trauma or injury associated with athletic cycling events.

I hereby waive, release, and discharge for myself, my heirs, executors, administrators, legal representatives, assigns, and successors in interest (hereinafter collectively successors) any and all rights and claims which I have or may hereafter accrue to me again the sponsor(s) of this event, the Waxahachie Rotary Club, its members, officers and agents, the promoter and any promoting organization(s), proper owners, law enforcement agencies and all public entities through or by which the events will be held for any and all damages which may be sustained by me directly or indirectly in connection with or arising out of my participation in or association with the event, or travel to and return from the event.

I agree it is my sole responsibility to be familiar with the course, the rules, and any specific regulations for the event. I understand and agree that situations may arise during the ride which may be beyond the immediate control of the ride officials or organizers, and I must continually ride so as to neither damage myself or others. I accept responsibility for the condition and adequacy of my equipment. I have no physical or medical condition which to my knowledge would endanger myself or others or would interfere with my ability to participate in this event. I further agree that if I choose to participate in this ride and not wear an approved helmet, I can be subject to serious head injury and assume all liability and responsibility for injuries arising from failure to do so.

I agree, myself, my heirs, administrators, legal representatives and successors and assigns, that the above representatives are contractually binding and are not mere recitals, and that should I or any successors assert my claim in contravention of this agreement, I or my successors shall be liable for all expenses (including legal fees) incurred by the other party or parties in defending, unless the party or parties are fully adjudged liable on such claim for willful or wanton negligence. This agreement may not be modified orally, and a waiver of any provisions shall not be construed as a modification of any provision herein or as consent to any subsequent waiver or modification. I also grant full permission to any and all spons0rs to use photographs, photography and records of this event for any purpose.

______

Riders SignatureDate of signature