2014 Tour du Port au Port
Contact Information
Name:____________________________________
Mailing Address:____________________________
City:______________________________________
Prov/State:________________________________
Post/Zip:__________________________________
Country:__________________________________
Phone:____________________________________ E-mail:____________________________________
Local Address (if different than above):_____________________________________________________
Local Phone (if different than above):_______________________________________________________
Athlete Information
 Male
 Female
 First-Time (Tour du Port au Port)?
 Mother?
 Father?
BNL Number:______________________________
Date of Birth (mm/dd/yy):____________________
MCP:_____________________________________
Medical Conditions:_____________________________________________________________________
Medication:___________________________________________________________________________
Emergency Contact (name & phone):_______________________________________________________
Event Categories
 Select the appropriate category:
 A-You live on your bike
 B-Weekend Warrior
 C-You get out when you can
 D-Is there really padding
in those shorts?
 Select an event category/distance:
 Short distance C&D only (approx. 60 km)
 Long distance A&B (115km)
 Long distance C&D (115km)
 Time trial C&D (15km)
 Time trial A&B (15km)
Date:
Athlete Check In:
Sunday, August 24th
9:00 a.m.
Categories C&D 115 km Race Start:
10:00 a.m.
Categories A&B 115 km Race Start:
11:00 a.m.
Categories C&D 60 km Race Start:
12:30 p.m.
Start/Finish Location:
Our Lady Mercy Complex
Banquet:
5:00 p.m. at Our Lady Mercy Complex
Event Fee and Payment
Early bird rate with time trial (Before August 12th):
th
Early bird rate without time trial (Before August 12 )
th
$50.00 + BNL Membership
$40.00 + BNL Membership
Regular rate with time trail (After August 12 )
Regular rate without time trial (After August 12th):
Select a method of payment:
$60.00 + BNL Membership
$50.00 + BNL Membership
 Cash
 Visa
 Cheque*
 Debit
 Mastercard
*Please make cheques payable to “Cycle Solutions Events”
If paying by credit card, please complete the following information:
Card Number:______________________________
Expiry Date:____/____
Name on Card:_____________________________
CVC # (3-digit back of card):___________________
Signature:_____________________________________________________________________________
Release of Liability, Waiver of Claims, Assumption of Risk and Indemnity Agreement
By signing this document you will waive certain legal rights including the right to sue.
PLEASE READ CAREFULLY!
Athlete’s Name: ___________________________________________
(Please Print Clearly)
Assumption of Risk
I am aware that the West Coast Cycling Association (hereinafter referred to as “the Cycling Club”) have
in addition to the usual dangers and risks inherent to the sport of cycling, certain additional dangers and
risks including, but not limited to, the danger and risk of collision with natural and man-made objects
and with other cyclists and spectators and I freely accept and fully assume all such dangers and risks and
the possibility of personal injury, death, property damage or loss resulting there-from.
Release of Liability
In consideration of the Cycling Club permitting my participation in the West Coast Cycling Association,
racing and other events (hereinafter referred to as “the Program”), I hereby agree as follows:
1. TO WAIVE ANY AND ALL CLAIMS that I may have against the Cycling Club, the event, the event
sponsors, and their directors, officers, employees, agents, and representative, and any volunteers in
any way associated with the event (all of whom are hereinafter collectively known as “the
Releasees”).
2. TO RELEASE THE RELEASEES FROM ANY AND ALL LIABILITY for any loss, damage, injury, or expenses
that I may suffer or that my next of kin may suffer as a result of my participation in the event due to
any cause whatsoever, including but not limited to, negligence, breach of contract, breach of
statutory duty of care or breach of any other duty of care.
3. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability from property
damage or personal injury to any third party, resulting in my participation in the event or use of the
Cycling Club and its facilities; and that, this Release of Liability shall be effective and binding upon
my heirs, next of kin, executors, administrators and assigns in the event of my death.
I am the full age of eighteen (18) years and I have read and understood this Release of Liability prior to
signing it, and I am aware that by signing this Release of Liability I am waiving certain legal rights which I,
or my heirs, next of kin, executors, administrators, and assigns may have against the Releasees.
Signed this ________ day of __________________, 20____
Signature of Athlete
Signature of Parent/Guardian (if athlete is under 18)
Signature of Witness