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RACE REGISTRATION FORM
Reanna’s
Cycle of Hope
Wishes to
Thank these
Sponsors &
Supporters
for their
Generous
Contributions:
2015
September 12th, 2015
from 9:30 am to 2:00 pm
Howard Watson Trail
Race Participant
First Name: _____________________ Intial: _____ Last Name: ______________________________
Date of Birth (MM/DD/YYYY): _____/______/__________ Age on Race Day: _____ Sex: M
F
Rob Simrak
Magic Realty Inc.
Address: ___________________________________________________________________________
City: _______________________________ Province: ______ Postal Code: ____________________
Phone Number: (_____)________________ E-mail: ________________________________________
Participation Level (check one): Cycle 40KM
Registration Cost
Cycle 20KM
Walk/Run 5KM
T-Shirt Sizes
$75.00 Family of four: 2 adults, 2 children
Youth:
XS
S
M
L
$25.00 for adults
Women’s: XS
S
M
L
XL
$20.00 for youth 12 & under
Men’s:
M
L
XL
XXL
S
Registration includes: T-shirt, Gift Bag, and BBQ following the completion of event.
Three Registration & Payment Options
1) Payment (cheques payable to Reanna’s Cycle of Hope), and registration forms can be mailed to:
Reanna’s Cycle of Hope, c/o Body Balance Physiotherapy, 1317 Exmouth St., Sarnia ON, N7S 3Y1
2) Registration forms and payments/donations can be dropped off at any Scotiabank location in Sarnia and Brights Grove
c/o Reanna’s Cycle of Hope.
3) Register and make payment/donation online at: www.reannascycleofhope.com through PayPal
For More Information, Call: 519.402.2679, or Email: [email protected]
Release, Waiver and Indemnity
In consideration of the acceptance of my Application for Registration and permission to participate as an entrant in “Reanna’s Cycle of Hope” and post cycle activities (the “Event”) on September 12, 2015, I agree as follows. I acknowledge
that biking is a risky and hazardous activity and that falls, collisions, injuries and related damage are a common and ordinary occurrence of biking and related activities. I understand that risks and conditions vary constantly and such risks
and hazards include but are not limited to weather, use, variations in terrain, surface conditions, other vehicles, other bikers and pedestrians, obstacles and such other hazards inherent in the risks of biking. I agree to accept the risks and take
full responsibility for any and all injuries to myself and/or others and for property damage that may occur as a result of my participation in the Event as a racer, spectator or otherwise. I agree that I will not make any claims against the
Event organizers, Event sponsors and Event volunteers and others associated with the Event including without limiting the forgoing the Municipality of the City of Sarnia, the Corporation of the County of Lambton, Make-A-Wish® Foundation
Southwestern Ontario, their respective owners, operators, agents, employees, affiliates and volunteers for any injury or harm to me due to their alleged negligence or other cause. I agree on my own behalf and also on behalf of my heirs,
executors and assigns to voluntary assume all risk of personal injury, death, property loss or damage of any kind. I agree to RELEASE, INDEMNIFY and SAVE HAMLESS all Event organizers, Event sponsors and Event volunteers, officials, vendors,
consultants including without limiting the forgoing the Municipality of the City of Sarnia, the Corporation of the County of Lambton, Make-A-Wish® Foundation Southwestern Ontario, their respective owners, officers, directors, representatives,
operators, agents, employees, affiliates and volunteers (the “Releasees”) of and from any and all claims, demands, costs, actions, expenses, losses and any other liability in respect of such injury, death and damage sustained or arising from
or in any way related to the Event or to my participation in the Event whether caused by the alleged negligence or wilful misconduct of the Releasees or by any other person or cause. I agree that if any portion of this agreement is deemed
to be unenforceable all other parts shall remain in full force and effect. I agree that this agreement is governed by and subject to the laws of the Province of Ontario and no other jurisdiction.
ONLY COMPLETE SECTION BELOW IF YOU ARE A PARENT OR GUARDIAN OF A PARTICIPANT UNDER THE AGE OF 18
I represent and warrant that I am the parent or guardian of the above named participant ("Minor"). I give my approval for the Minor's participation in the Event. I assume all risks and hazards incidental to the Minor's participation in the
Event and I release, absolve, indemnify and agree to hold harmless the Releasees from any claim arising out of an injury to the Minor and from any Claims, arising out of or connected with the Minor's participation in the Event. I consent
to the foregoing and grant permission for the Minor to participate in the Event. I acknowledge I have carefully read, accepted and agreed to the terms of this Waiver and Release, Assumption of Risk and know and understand its terms.
Signature:
(parent/guardian if under 18)
PLEDGE FORM
Sponsor’s Name
Address
City/Postal Code
Phone
Amount
Pledged
Please Print Clearly
2015
September 12th, 2015
from 9:30 am to 2:00 pm
Howard Watson Trail
Make-A-Wish® 307 Commissioners Rd. West,
London, ON N6J 1Y4
Ph: (519) 471-4900 Fax: (519) 471-4933
E-mail: [email protected]
We grant the wishes of children with
life-threatening medical conditions
to enrich the human experience
with hope, strength and joy.
Cheques issued to Make-A-Wish® in the amount
of $20 or more will be receipted. The receipt
will be issued in the name of the cheque holder.
Charitable Registration #82712 1302 RR0001
Cash Total
Cheque Total
PAGE TOTAL
Total
Paid
Payment
Method