SWISS CHEESE
REGISTRATION FORM and WAIVER & RELEASE
Please complete the information below and mail with payment and signed Waiver & Release to:
Derks Cycle
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Name (first, last): ___________________________________________________________________
Street Address: _____________________________________________________________________
City:
Phone #: _________________________ Email address: ___________________________________
Emergency Contact Name and phone #: _________________________________________________
Gender (circle one): M F Age: ______ (all participants must be 16 years or older)
Roommate Name*: ______________________________________________________
Note: If you are interested in attending this trip and don’t have a roommate but are willing to share a room with another person of the same gender, please indicate as such in the space provided. You will be contacted once a roommate has been found for you.
Tour Fees*:
Swiss Cheese & Spotted Cows (double occupancy): $695/person
Swiss Cheese & Spotted Cows (single occupancy): $930/person
* Tour fee includes five nights lodging (Tue-Sat), 4 breakfasts (combination
of hot & continental), 3 dinners, Swiss entertainment and live music in New
Glarus, cheese factory tour, brewery tour, baggage transport to each night’s
destination, maps, and SAG & mechanical support. All other fees are on your own.
Cancellation Policy:
All cancellations received on or before
Waiver and Release - Read
Carefully - This is a contract with legal consequences.
I,
the undersigned, know that bicycle tours are potentially hazardous events, and
attend them out of my own free will and choice. In choosing to attend the Swiss
Cheese and Spotted Cows tour and any related events or activities, I fully
accept and assume all risks, whether before, during or after the event and
related events or activities. These include, without limitation, risks of
physical injury, mental injury, emotional stress, trauma, death, contact with
other participants, equipment failure, inadequate safety equipment, the effects
of weather including extreme temperature or conditions, traffic, contact with
motor vehicles of all types and descriptions, collision with other riders or
fixed objects, the conditions of the road, theft, camping, and participating in
events or activities along the route. All risks are known and appreciated by
me. I waive any and all specific notice of the existence of risks. I agree that
leaders and maps are provided for my convenience only and not to guaranty a
safe route or trip. I shall assume and pay my medical and emergency expenses in
the event of injury, illness or other incapacity regardless of whether I
authorized such expenses. I realize that bicycle touring requires physical
conditioning and I represent that I am in sound medical condition capable of
participating in the ride without risk to myself or others. I have no medical
impediment that would endanger myself or others. I
understand that situations may arise during bicycle tours that may be beyond
the control of sponsors, promoters and organizers. I will be solely responsible
for the condition and adequacy of my bicycle, safety gear and riding equipment.
I will ride safely within the limits of my own abilities, my equipment and the
riding conditions and in a manner so as not to endanger myself or others. Knowing these facts and in consideration of
my nonrefundable entry, acceptance, admission to and participation in this tour
and its related events and activities, I, for myself and anyone acting on my
behalf, waive, release, discharge, indemnify, covenant not to sue and agree to
hold Swiss Cheese & Spotted Cows, Mary Derks, Derks Cycle Tours LLC, all
other sponsors and participating clubs, communities, school districts and
organizations, event officials, emergency and support personnel, volunteers and
their representatives, and the officers, directors, employees, representatives,
agents, insurers, insurance brokers and successors of all of the above,
harmless from any and all claims, demands and actions of any and every kind
that I have, may have or may hereafter accrue against the released parties,
directly or indirectly, arising out of or relating in any respect to my
attendance or participation in this event and its related events and
activities, including, without limitation, litigation expenses, attorney fees,
loss liability, damages or costs. My waiver and release of all claims, demands,
actions and liability shall include, without limitation, any injury, damage or
loss to my person or property which may be caused by any act, or failure to
act, by the above-identified persons and entities or sustained by me before,
during or after this event and its related events and activities. I agree to
abide by all event rules and regulations. I waive my rights of privacy or
publicity and grant permission to all of the foregoing to use any photographs,
motion pictures, videotapes, recording or other record of this event for any
legitimate purpose. I further agree to indemnify and hold the parties released
above harmless from any and all losses, damages, claims and expenses, including
attorneys fees, arising from or relating in any
respect to my participation in this event or its related events and activities.
If I am a minor my parent or guardian is also signing on my behalf and we both
agree to be bound by the terms of this agreement, waiver and release. If I am
the parent and/or legal guardian of a minor participant, I certify that the
minor is in good health, qualified and in proper physical condition to
participate in this event and I hereby release, discharge, covenant not to sue,
and agree to indemnify and save and hold harmless all of the above released
parties from all liability, claims, demands, losses or damages on the minor’s
account incurred in connection with this event or its related events and
activities. I will indemnify, save and hold harmless each of the released
parties from any litigation expenses, attorney fees, loss liability, damage or
cost that may occur as the result of any such claims in connection with the
minor’s participation in this event and its related events and activities.
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Signature (Signature of parent
or guardian if 17 or under) Date
WAIVER MUST
BE SIGNED or registration will be returned.