A nonprofit youth ski instruction program
Dear Junior Racer and Parent(s),
November 14, 2012
Another ski season is about to begin! This year we will begin our season with an
important meeting on Wednesday, November 14th in the West Annex Room of the Four
Lakes Lodge. We will be available for registration beginning at 6:30 p.m. Our meeting
will begin at 7:00 p.m. At that time, we will be discussing practices and race schedules,
and signing up for volunteer worker schedules. All racers and parent(s) need to
attend.
Enclosed in this mailing you will find the following:
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Four Lakes Jr. Racing Medical Release/Registration Form
General Waiver and Release of all Claims
Four Lakes Code of Conduct Form
WIJARA Code of Conduct Athlete and Parents Form
Board Members and Head Coach for 2012-2013
Four Lakes Jr. Racing race dates and practice schedule
Sundown Mountain Release of Liability
W.I.J.A.R.A. Release of Liability – 4 SIGNED COPIES
OF THIS
LIABILITY NEED TO BE COMPLETED – ONE FOR
EACH RACE HILL
All of the forms in this packet (4 COPIES OF THE W.I.J.A.R.A. Form and the
Sundown Mountain Form NEED TO BE INCLUDED) need to be completed and
brought to registration night. Please fill out a separate set of forms for each racer. Fees
paid are refundable only until December 1, 2012. The fee for 2102-2103 will remain
$200 plus $30 for WIJARA fees. These fees are to be paid in one check for $230 per
child. Checks should be made payable to Four Lakes Jr. Racing.
Four Lakes is offering a season pass for $150 to all members, which will permit
unlimited use of the ski hill for the season. This fee will be paid by separate check on
registration night and should be made payable to Four Lakes. Picture season passes
will again be used this year. Four Lakes will have a photographer available on
registration night and ID pictures will be taken at this time. Photo ID’s can only be taken
after the $150 season pass fee is paid to Four Lakes.
The Four Lakes Race Team is co-host with Chestnut in the running of their race the
weekend of 1/12 and 1/13. We will need to fill a variety of volunteer roles and will ask
all parents step up to be available to work this race. This will be our major responsibility
for the race season. In addition to this race, each race team will provide volunteer
gatekeepers for the rest of the races, so each family will need to commit to one other
job during the season. Please bring your calendar with you to registration night to sign
up for worker positions. Parents run our organization and the success of our race
season depends upon your help at each race. We will sign up for specific races/runs so
make sure you note your commitment. If you don’t pick a spot, we’ll assign one.
If you are not able to join us for registration night, please call Elaine Eckert
(630.479.3064) to arrange delivery of registration packets. We must receive registration
papers and fees by registration night as we have a waiting list of eager skiers. We look
forward to seeing you on November 14th!
Elaine Eckert
Secretary
Four Lakes Jr. Race Team
Phone: 630.479.3064
eckerte@mcdmgmt.com
5020 Barickman Ct
Oswego, Il 60543
Four Lakes Jr. Racing
Medical Release/Registration Form
2012-2013 Season
In the event that my child, ____________________________, a minor, becomes
ill or injured while participating in a Four Lakes Jr. Racing Club and/or WIJARA activity,
during my absence, I hereby grant permission to the officials, coaches, and/or
volunteers to seek and authorize necessary medical attention for my child. I also give
permission to transport, if necessary, by ambulance, automobile, or other means my
child to the nearest medical facility. I understand I will be responsible for any usual,
customary, and reasonable charges incurred on behalf of my child for medical
treatment.
Name of Child: __________________________________
Date of Birth:_____________________
Home Address:_______________________________
City, State, Zip:________________________
Home Phone: _____________________________
Parents e-mail: ________________________
Allergies: _________________________________
Last Tetanus Shot: _____________________
Father’s Name and Place of Work: ______________________________________________________
Address: ___________________________________
Phone: ______________________________
Mother’s Name and Place of Work:______________________________________________________
Address: _____________________________________ Phone: ______________________________
Primary Insurance Company: _________________________
Address: __________________________________
Phone: ______________________________
Group/Policy Number: ______________________
Policyholder:__________________________
ID#: ______________________________________________
S ig n at ur e of C us to d i al p ar en t or l e ga l g u ar di an
Name
Date
In emergency, please contact:
______________________________________________@____________________________________
GENERAL WAIVER AND RELEASE OF ALL CLAIMS
Please read this form carefully and be aware in registering your minor child/ward for participation in the
Four Lakes Junior Racing Club as you will be waiving and releasing all claims for personal injuries, death
or property damage or loss you or your minor child/ward might sustain arising out of participation in the
Four Lakes Junior Racing Club’s activities.
I recognize and acknowledge that there are certain attendant risks of physical injury associated with
downhill skiing, racing and related ski activities and I agree to assume the full risk of any personal injuries,
death, property damages, or loss regardless of severity which I or my minor child/ward may sustain as a
result of participating in the Four Lakes Junior Racing Club or associated with the training, racing or other
Four Lakes Junior Racing Club activities or while at a W.I.J.A.R.A sponsored event.
I agree to waive and relinquish all claims I or my child/ward may have for personal injuries, death,
property damage or loss as a result of participating in the Four Lakes Junior Racing Club and
W.I.J.A.R.A. sponsored events against the Four Lakes Junior Racing Club and W.I.J.A.R.A. and all its
instructors, coaches, officers, directors, agents, board members, volunteers, servants and employees.
I do hereby fully release and discharge the Four Lakes Junior Racing Club and W.I.J.A.R.A. and its
instructors, coaches, officers, directors, agents, board members, volunteers, servants, and employees
from any and all claims from personal injuries, death, property damage or loss which I or my minor
child/ward may have or which may accrue to me or my minor child/ward and arising out of, in connection
with, or in any way associated with the activities of the Four Lakes Junior Racing Club.
I further agree to indemnify and hold harmless and defend the Four Lakes Junior Racing Club and
W.I.J.A.R.A. and its instructors, coaches, officers, directors, agents, board members, volunteers, servants
and employees from any and all claims resulting from personal injuries, death, property damage and
losses sustained or caused by me or my minor child arising out of, in connection with, or in any way
associated with the activities of the Four Lakes Junior Racing Club and W.I.J.A.R.A.
The undersigned further acknowledges that the undersigned is solely responsible for his/her
child’s/ward’s personal skiing equipment including its maintenance and any adjustments related to same.
I have read and fully understand the above Waiver and Release of all Claims.
IN WITNESS WHEREOF I HAVE SIGNED THIS RELEASE FORM THIS _________ DAY OF _____________
__________________________________________
Signature of Parent/Guardian
_______________________
Date
__________________________________________
Signature of Parent/Guardian
_______________________
Date
_________________________________________
Junior Racer Name (please print)
(Witness line below will be completed at the registration night)
WITNESS:
_________________________________
_______________________
Date
Four Lakes Junior Racing Code of Conduct
This is to be read and signed by both parent and child.
Four Lakes Junior Racers are representatives of the Four Lakes
Management and as such are expected and required to display proper skiing and
social etiquette to the skiing and other public at all times whether in your racing bib
or during free skiing. This includes being polite and helpful in your attitude toward
the skiing public; taking your turn in lift lines, being polite at all times, willing to help
someone in difficulty and in not cutting through classes which are in progress,
playing tag, throwing snowballs or other disruptive behavior including interfering
with other skiers bindings.
Anyone who does not follow these rules will be warned the first time they
commit a violation. In the event of a second occurrence of any violation, the
parents of the offender will be notified and the offender will be removed from the
team for one week. A third offense by any racer will cause removal from the team
on a permanent basis.
SIGNED ON THIS_________DAY OF__________________, 2012
_____________________________________
PARENT/GUARDIAN
_____________________________________
JUNIOR RACER
WIJARA CODE OF CONDUCT
ATHLETES AND PARENTS
You are expected to conduct yourself in a sportsmanlike manner. You are responsible
for your actions in races, going to and from races, and while at areas hosting races.
You are responsible for your knowledge of race rules and procedures.
Unsportsmanlike conduct will result in disqualification from an event and a 2nd offense
will prevent you from participating in future events.
Good sportsmanship shall include, among other things:
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Respect for all race officials, ski area employees, and the skiing public.
Suitable dress and grooming; courtesy and good manners in public places.
Self-control, responsible behavior, consideration for others physical and
emotional well-being, no profane or abusive language; mature conduct.
Respect for private and public property.
Abstinence from the illegal use of alcohol and drugs.
Respect for all lift facilities, lift privileges and operating procedures, and closed
areas.
Honest conduct, no theft or misrepresentation whatsoever.
Attendance at awards ceremonies and receptions encouraged.
I have read, understand, and agree to follow the guidelines explained above.
Signature of Athlete__________________________
Date_____________
Print Athlete Name __________________________
Signature of Parent(s)_________________________
Date______________
_________________________
Date ______________
Four Lakes Junior Racing
Coaches and Board Members for 2012-2013
Coaches
John Bendik (Head Coach)
(H) 630-969-2621
(C) 630-329-9649
(W) 708-531-0777
Jbendik@norkol.com
Dave Gabrielese
(H) 773-252-8602
davegabrielese@yahoo.com
Alyssa Bendik
(H) 630-969-2621
Jacob Bendik
(H) 630-969-2621
Board Members
President
Vice President
Treasurer
Secretary
Race Volunteers
Social
Social
Web/Clothing
David Hummel
Wayne & Joanne Shisler
Karl Mueller
Elaine Eckert
Steve Coates
Lynne Culberson
Suzyn Price
Tom Eckert
(630) 369-6859
(630) 416-0492
(630) 369-5689
(630) 479-3064
(630) 355-6153
(630) 420-6280
(630) 907-5682
(630) 479-3063
Four Lakes Racing Website:
Four Lakes Snow Conditions
David.Hummel@jetlitho.com
wshisler@ameritech.net
kwmueller@mac.com
eckerte@mcdmgmt.com
ghilasail@yahoo.com
carolyn_culberson@yahoo.com
dspricesox@gmail.com
tom@ideasinadvertising.com
www.fourlakesracing.org
www.skifourlakes.com/
WIJARA Race Dates 2013
January 12 & 13
Chestnut
January 26 & 27
Sundown
February 2 & 3
Cascade
February 23 & 24
Tyrol Basin
Four Lakes Racing Practice Schedule
Practices start as soon as there is enough snow at Four Lakes, usually mid to late December. The
team practices three times per week, unless there is a race.
Ages 12 & under
Tuesday
6:00 – 7:00 p.m.
Thursday
6:00 – 7:00 p.m.
Saturday
9:00 – 11:00 a.m.
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Ages 13 & over
7:00 – 8:30 p.m.
7:00 – 8:30 p.m.
9:00 – 11:00 a.m.
The “Candy Bar” Race (intra-squad) will be held in February.
The annual awards banquet will be held in March at the Four Lakes Lodge.
SUNDOWN MOUNTAIN - RELEASE OF LIABILITY
I, the Participant in a WIJARA event at Sundown Mountain or parent or legal guardian of a Participant,
know, understand and agree that skiing and snowboarding involve both known and unknown risks, dangers,
and hazards.
Signing on my own behalf, I agree as a condition of being allowed to use the ski area facility and premises
that I freely accept and voluntarily assume all risks of personal injury, death, or property damage, AND I
RELEASE, INDEMNIFY AND HOLD HARMLESS SUNDOWN MOUNTAIN AND ITS AGENTS,
EMPLOYEES, VOLUNTEERS, DIRECTORS, OFFICERS AND SHAREHOLDERS FROM ANY AND
ALL LIABILITY WHICH RESULTS IN ANY WAY FROM ITS ALLEGED NEGLIGENCE OR FAULT,
CONDITIONS ON OR ABOUT THE PREMISES AND FACILITIES, THE OPERATIONS OF THE SKI
AREA (INCLUDING, BUT NOT LIMITED TO, GROOMING, SNOW MAKING, SKI LIFT
OPERATIONS, SKI PATROL OPERATIONS, ACTIONS OR OMISSIONS OF EMPLOYEES,
VOLUNTEERS, OR AGENTS OF THE AREA), OR MY PARTICIPATION IN
SKIING/SNOWBOARDING/RIDING OR OTHER ACTIVITIES AT THE AREA, ACCEPTING FOR
MYSELF THE FULL RESPONSIBILITY AND LIABILITY FOR ANY AND ALL DAMAGE OR
INJURY OF ANY KIND WHICH MAY RESULT.
Signing on behalf of another (as parent or legal guardian), I agree TO DEFEND, INDEMNIFY, AND HOLD
HARMLESS SUNDOWN MOUNTAIN AND ITS AGENTS, EMPLOYEES, VOLUNTEERS,
DIRECTORS, OFFICERS AND SHAREHOLDERS FROM ANY AND ALL LIABILITY WHICH
RESULTS IN ANY WAY FROM ITS ALLEGED NEGLIGENCE OR FAULT, CONDITIONS ON OR
ABOUT THE PREMISES AND FACILITIES, THE OPERATIONS OF THE SKI AREA (INCLUDING,
BUT NOT LIMITED TO, GROOMING, SNOW MAKING, SKI LIFT OPERATIONS, SKI PATROL
OPERATIONS, ACTIONS OR OMISSIONS OF EMPLOYEES, VOLUNTEERS, OR AGENTS OF THE
AREA), OR PARTICIPANT=S SKIING/SNOWBOARDING/RIDING OR OTHER ACTIVITIES AT THE
AREA, AGREEING TO DEFEND, INDEMNIFY, AND HOLD HARMLESS SUNDOWN MOUNTAIN
ON ANY CAUSE OF ACTION WHICH MAY RESULT FROM MINOR PARTICIPANT=S USE OF THE
PREMISES.
Further, I agree to visually inspect the ski trail prior to the event in which I will be participating. If I am not
willing to accept the risk of injury associated with the event I will not participate.
In signing below, I certify that I have read, understand and accept this Release of Liability Agreement. I also
understand this Release of Liability to be legally binding.
Date:___________________
_______________________________
(Participant's Signature)
_________________________________________________________________
(Please Print Your Name)
_________________________________________________________________
(Signature of Parent or Guardian if participant is under 18 years of age)
You Will Find Four Copies of
the Next Document-
Please Complete
Four Copies for Each Racer!!
Rev 9/12
WIJARA RELEASE OF LIABILITY
I, the participant and/or parent of a participant in a WIJARA race event at Chestnut Mountain, Sundown Mountain,
Cascade Mountain, Granite Peak, Mt. La Crosse and/or Tyrol Basin know, understand and agree that skiing and ski
racing involve both known and unknown risks, dangers and hazards. These risks, dangers and hazards include, but
are not limited to, changing weather and snow conditions, changing trail conditions, variations in steepness and
terrain, natural and man-made obstacles and structures, equipment failure, collisions with objects or structures, being
struck by skiers/riders or equipment, and exceeding my own abilities. Ski terrain may have moguls, forest growth,
trees, rocks and debris, lift towers, snowmaking equipment and moving or stopped skiers/riders. I agree, as a
condition of being allowed to use the ski area facility and premises, and to participate or for my child to participate
in the above ski races, that I freely accept and voluntarily assume all risks of personal injury or death or property
damage,
And I hereby release, indemnify and hold harmless Chestnut Mountain Ski Corp., Chestnut Mountain
Resort, Inc., and Galena Lodge Corp., Sundown Mountain, MGV Corp., Cascade Mountain, Inc., Cascade
Mountain Management Corporation, Cascade Mountain Land Holdings LLC, Granite Peak Corporation,
Mt. La Crosse, Inc. and/or Tyrol Basin and their agents, employees, volunteers, directors, officers and
shareholders from any and all liability for personal injury or property damage which results in any way from
their negligent acts or omissions, the conditions on or about the premises and facilities, the operations of the
ski area, including, but not limited to, grooming, snow making, ski lift operations, ski patrol operations,
actions or omissions of employees, volunteers or agents of the area, or my participation or my child’s
participation in skiing or other activities at the area, accepting for myself or my child the full responsibility
and liability for any and all such damage or injury of any kind, which may result.
Further, I agree to visually inspect the ski trail prior to the event in which I will be participating. If I am not willing
to accept the risk of injury associated with the event, I will not participate. In signing below, I certify that I have
read, understand and accept this Release of Liability Agreement. I also understand this Release of Liability to be
legally binding.
CAUTION, READ BEFORE SIGNING! THIS RELEASE IS VALID FOR FIRST
COMPETITION SEASON FOLLOWING DATE SIGNED ONLY!
Signed: ______________________________________________________ Date: _____________
(Participant's Signature)
_____________________________________________________________
(Print participant’s name legibly)
Team name: _________________________________________________ Bib No. ____________
Personal Insurance Coverage
Company _____________________________ Identification # _________________________
Policy # ______________________________ Expiration Date _________________________
______________________________________________________________ Date: _____________
Signature of Mother or Legal Guardian, if participant is under 18 years of age
______________________________________________________________
Print mother or guardian’s name legibly, if participant is under 18 years of age
______________________________________________________________ Date: _____________
Signature of Father or Legal Guardian, if participant is under 18 years of age
______________________________________________________________
Print father or guardian’s name legibly, if participant is under 18 years of age
Emergency Contact Telephone Number: __________________________________________________
Rev 9/12
WIJARA RELEASE OF LIABILITY
I, the participant and/or parent of a participant in a WIJARA race event at Chestnut Mountain, Sundown Mountain,
Cascade Mountain, Granite Peak, Mt. La Crosse and/or Tyrol Basin know, understand and agree that skiing and ski
racing involve both known and unknown risks, dangers and hazards. These risks, dangers and hazards include, but
are not limited to, changing weather and snow conditions, changing trail conditions, variations in steepness and
terrain, natural and man-made obstacles and structures, equipment failure, collisions with objects or structures, being
struck by skiers/riders or equipment, and exceeding my own abilities. Ski terrain may have moguls, forest growth,
trees, rocks and debris, lift towers, snowmaking equipment and moving or stopped skiers/riders. I agree, as a
condition of being allowed to use the ski area facility and premises, and to participate or for my child to participate
in the above ski races, that I freely accept and voluntarily assume all risks of personal injury or death or property
damage,
And I hereby release, indemnify and hold harmless Chestnut Mountain Ski Corp., Chestnut Mountain
Resort, Inc., and Galena Lodge Corp., Sundown Mountain, MGV Corp., Cascade Mountain, Inc., Cascade
Mountain Management Corporation, Cascade Mountain Land Holdings LLC, Granite Peak Corporation,
Mt. La Crosse, Inc. and/or Tyrol Basin and their agents, employees, volunteers, directors, officers and
shareholders from any and all liability for personal injury or property damage which results in any way from
their negligent acts or omissions, the conditions on or about the premises and facilities, the operations of the
ski area, including, but not limited to, grooming, snow making, ski lift operations, ski patrol operations,
actions or omissions of employees, volunteers or agents of the area, or my participation or my child’s
participation in skiing or other activities at the area, accepting for myself or my child the full responsibility
and liability for any and all such damage or injury of any kind, which may result.
Further, I agree to visually inspect the ski trail prior to the event in which I will be participating. If I am not willing
to accept the risk of injury associated with the event, I will not participate. In signing below, I certify that I have
read, understand and accept this Release of Liability Agreement. I also understand this Release of Liability to be
legally binding.
CAUTION, READ BEFORE SIGNING! THIS RELEASE IS VALID FOR FIRST
COMPETITION SEASON FOLLOWING DATE SIGNED ONLY!
Signed: ______________________________________________________ Date: _____________
(Participant's Signature)
_____________________________________________________________
(Print participant’s name legibly)
Team name: _________________________________________________ Bib No. ____________
Personal Insurance Coverage
Company _____________________________ Identification # _________________________
Policy # ______________________________ Expiration Date _________________________
______________________________________________________________ Date: _____________
Signature of Mother or Legal Guardian, if participant is under 18 years of age
______________________________________________________________
Print mother or guardian’s name legibly, if participant is under 18 years of age
______________________________________________________________ Date: _____________
Signature of Father or Legal Guardian, if participant is under 18 years of age
______________________________________________________________
Print father or guardian’s name legibly, if participant is under 18 years of age
Emergency Contact Telephone Number: __________________________________________________
Rev 9/12
WIJARA RELEASE OF LIABILITY
I, the participant and/or parent of a participant in a WIJARA race event at Chestnut Mountain, Sundown Mountain,
Cascade Mountain, Granite Peak, Mt. La Crosse and/or Tyrol Basin know, understand and agree that skiing and ski
racing involve both known and unknown risks, dangers and hazards. These risks, dangers and hazards include, but
are not limited to, changing weather and snow conditions, changing trail conditions, variations in steepness and
terrain, natural and man-made obstacles and structures, equipment failure, collisions with objects or structures, being
struck by skiers/riders or equipment, and exceeding my own abilities. Ski terrain may have moguls, forest growth,
trees, rocks and debris, lift towers, snowmaking equipment and moving or stopped skiers/riders. I agree, as a
condition of being allowed to use the ski area facility and premises, and to participate or for my child to participate
in the above ski races, that I freely accept and voluntarily assume all risks of personal injury or death or property
damage,
And I hereby release, indemnify and hold harmless Chestnut Mountain Ski Corp., Chestnut Mountain
Resort, Inc., and Galena Lodge Corp., Sundown Mountain, MGV Corp., Cascade Mountain, Inc., Cascade
Mountain Management Corporation, Cascade Mountain Land Holdings LLC, Granite Peak Corporation,
Mt. La Crosse, Inc. and/or Tyrol Basin and their agents, employees, volunteers, directors, officers and
shareholders from any and all liability for personal injury or property damage which results in any way from
their negligent acts or omissions, the conditions on or about the premises and facilities, the operations of the
ski area, including, but not limited to, grooming, snow making, ski lift operations, ski patrol operations,
actions or omissions of employees, volunteers or agents of the area, or my participation or my child’s
participation in skiing or other activities at the area, accepting for myself or my child the full responsibility
and liability for any and all such damage or injury of any kind, which may result.
Further, I agree to visually inspect the ski trail prior to the event in which I will be participating. If I am not willing
to accept the risk of injury associated with the event, I will not participate. In signing below, I certify that I have
read, understand and accept this Release of Liability Agreement. I also understand this Release of Liability to be
legally binding.
CAUTION, READ BEFORE SIGNING! THIS RELEASE IS VALID FOR FIRST
COMPETITION SEASON FOLLOWING DATE SIGNED ONLY!
Signed: ______________________________________________________ Date: _____________
(Participant's Signature)
_____________________________________________________________
(Print participant’s name legibly)
Team name: _________________________________________________ Bib No. ____________
Personal Insurance Coverage
Company _____________________________ Identification # _________________________
Policy # ______________________________ Expiration Date _________________________
______________________________________________________________ Date: _____________
Signature of Mother or Legal Guardian, if participant is under 18 years of age
______________________________________________________________
Print mother or guardian’s name legibly, if participant is under 18 years of age
______________________________________________________________ Date: _____________
Signature of Father or Legal Guardian, if participant is under 18 years of age
______________________________________________________________
Print father or guardian’s name legibly, if participant is under 18 years of age
Emergency Contact Telephone Number: __________________________________________________
Rev 9/12
WIJARA RELEASE OF LIABILITY
I, the participant and/or parent of a participant in a WIJARA race event at Chestnut Mountain, Sundown Mountain,
Cascade Mountain, Granite Peak, Mt. La Crosse and/or Tyrol Basin know, understand and agree that skiing and ski
racing involve both known and unknown risks, dangers and hazards. These risks, dangers and hazards include, but
are not limited to, changing weather and snow conditions, changing trail conditions, variations in steepness and
terrain, natural and man-made obstacles and structures, equipment failure, collisions with objects or structures, being
struck by skiers/riders or equipment, and exceeding my own abilities. Ski terrain may have moguls, forest growth,
trees, rocks and debris, lift towers, snowmaking equipment and moving or stopped skiers/riders. I agree, as a
condition of being allowed to use the ski area facility and premises, and to participate or for my child to participate
in the above ski races, that I freely accept and voluntarily assume all risks of personal injury or death or property
damage,
And I hereby release, indemnify and hold harmless Chestnut Mountain Ski Corp., Chestnut Mountain
Resort, Inc., and Galena Lodge Corp., Sundown Mountain, MGV Corp., Cascade Mountain, Inc., Cascade
Mountain Management Corporation, Cascade Mountain Land Holdings LLC, Granite Peak Corporation,
Mt. La Crosse, Inc. and/or Tyrol Basin and their agents, employees, volunteers, directors, officers and
shareholders from any and all liability for personal injury or property damage which results in any way from
their negligent acts or omissions, the conditions on or about the premises and facilities, the operations of the
ski area, including, but not limited to, grooming, snow making, ski lift operations, ski patrol operations,
actions or omissions of employees, volunteers or agents of the area, or my participation or my child’s
participation in skiing or other activities at the area, accepting for myself or my child the full responsibility
and liability for any and all such damage or injury of any kind, which may result.
Further, I agree to visually inspect the ski trail prior to the event in which I will be participating. If I am not willing
to accept the risk of injury associated with the event, I will not participate. In signing below, I certify that I have
read, understand and accept this Release of Liability Agreement. I also understand this Release of Liability to be
legally binding.
CAUTION, READ BEFORE SIGNING! THIS RELEASE IS VALID FOR FIRST
COMPETITION SEASON FOLLOWING DATE SIGNED ONLY!
Signed: ______________________________________________________ Date: _____________
(Participant's Signature)
_____________________________________________________________
(Print participant’s name legibly)
Team name: _________________________________________________ Bib No. ____________
Personal Insurance Coverage
Company _____________________________ Identification # _________________________
Policy # ______________________________ Expiration Date _________________________
______________________________________________________________ Date: _____________
Signature of Mother or Legal Guardian, if participant is under 18 years of age
______________________________________________________________
Print mother or guardian’s name legibly, if participant is under 18 years of age
______________________________________________________________ Date: _____________
Signature of Father or Legal Guardian, if participant is under 18 years of age
______________________________________________________________
Print father or guardian’s name legibly, if participant is under 18 years of age
Emergency Contact Telephone Number: __________________________________________________