XTERRA
DINO Triathlon Entry Form 2012
Mail entry
with check payable to: DINO LLC, PO Box 36395, Indianapolis IN 46236
Entry
Fees
-USA Triathlon members may subtract $12
Early
Registration -
due one week before the event. … SOLO: $70 … RELAY (per team): $120
Register early for
BOTH events at once and save $10! (solo entry only):
$130
Day-of-race
Registration - availability
subject to field limits … SOLO: $80 … RELAY (per team): $130
WHICH TRIATHLON? Versailles July
21____ Logansport Aug 11____ both____
Canoe Rental
$20 ___ Total Paid: _______
DIVISION: Triathlon___
Canoe/Kayak___
SOLO___ or RELAY TEAM:
All Male___ All Female___ Mixed___ Masters___
Relay members must
send entry forms together and use same Team Name at the bottom of this form.
DATE OF
BIRTH:
|__|__/__|__/__|__| “XTERRA AGE” on Dec 31 2012:
_____ SEX: M__ F__
LAST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
FIRST
NAME:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
STREET
ADDRESS:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
CITY:
ZIP: |__|__|__|__|__| PHONE#: (____)|__|__|__-__|__|__|__|
E-MAIL: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
T-SHIRT
SIZE:
S___ M___ L___ XL___
SWIM WAVE
PREFERENCE
(see SWIM WAVES section): Competitor____ Survivor____
PHYSICALLY CHALLENGED
DIVISION?
No___ Yes___
EMERGENCY
CONTACT INFO:
NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
PHONE#: (____)|__|__|__-__|__|__|__|
or SPECTATOR AT THE EVENT ___
TEAM/SPONSOR: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
OCCUPATION: _______________ TIDBIT
ABOUT YOURSELF: ________________________
WARNING: READ CAREFULLY. THIS
AGREEMENT INCLUDES A RELEASE OF LIABILITY AND WAIVER OF LEGAL RIGHTS AND
DEPRIVES YOU OF THE RIGHT TO SUE USA TRIATHLON AND OTHER PARTIES. DO NOT SIGN
THIS AGREEMENT UNLESS YOU HAVE READ IT IN ITS ENTIRETY.
SEEK THE ADVICE OF LEGAL COUNSEL IF
YOU ARE UNSURE OF ITS EFFECT.
2012 WAIVER AND RELEASE OF
LIABILITY,
ASSUMPTION OF RISK AND INDEMNITY
AGREEMENT
IN CONSIDERATION of USA Triathlon
(“USAT”) allowing me to participate in any USAT sanctioned event (the “Event”
or “Events”) as either a member of USAT or through the issuance of a single
event license or permit; I, for myself, and on behalf of my spouse, children,
parents, guardians, heirs and next of kin, and any legal and personal
representatives, executors, administrators, successors and assigns, hereby
agree to and make the following contractual representations pursuant to this
Waiver and Release of Liability, Assumption of Risk and Indemnity Agreement
(the “Agreement”);
1. I hereby represent that (i) I am in good health and in proper physical condition to
participate in the Event; and (ii) I am not under the influence of alcohol or
any illicit or prescription drugs which would in any way impair my ability to
safely participate in the Event. I agree that it is my sole responsibility to
determine whether I am sufficiently _t and healthy enough to participate in the
Event.
2. I understand and acknowledge the
physical and mental rigors associated with triathlon, duathlon,
or other multi-sport events, and realize that running, bicycling, swimming and
other portions of such Events are inherently dangerous and represent an extreme
test of a person’s physical and mental limits. I understand that participation
involves risks and dangers which include, without limitation, the potential for
serious bodily injury, sickness and disease, permanent disability, paralysis
and loss of life; loss of or damage to equipment/property; exposure to extreme
conditions and circumstances; accidents, contact or collision with other
participants, spectators, vehicles or other natural or manmade objects; dangers
arising from adverse weather conditions; imperfect course conditions; water,
road and surface hazards; equipment failure; inadequate safety measures;
participants of varying skill levels; situations beyond the immediate control
of the Event Organizers; and other undefined risks and dangers which may not be
readily foreseeable or are presently unknown (“Risks”). I understand that these
Risks may be caused in whole or
in part by my own actions or inactions,
the actions or inactions of others participating in the Event, or the acts,
inaction or negligence of the Released Parties defined below, and I hereby
expressly assume all such Risks and responsibility for any damages,
liabilities, losses or expenses which I incur as a result of my participation
in the Event.
3. I agree to be familiar with and to
abide by the Rules and Regulations established for the Event, including but not
limited to the Competitive Rules adopted by USAT and the Guide to Prohibited
Substances and Prohibited Methods of Doping adopted by the United States
Anti-Doping Agency.
I also accept sole responsibility for my
own conduct and actions while participating in the Event, and the condition and
adequacy of my equipment.
4. I hereby Release, Waive and Covenant
Not to Sue, and further agree to Indemnify, Defend and Hold Harmless the
following parties: USAT, the Event Owners, Organizers and Promoters, Race
Directors, Sponsors, Advertisers, Host Cities, United States Olympic Committee
(USOC), Local Organizing Committees, Venues and Property Owners upon which the
Event takes place, Law Enforcement Agencies and other Public Entities providing
support for the Event, and each of their respective parent, subsidiary and
affiliated companies, officers, directors, partners, shareholders,
members, agents, employees and volunteers
(Individually and Collectively, the “Released Parties” or “Event Organizers”),
with respect to any liability, claim(s), demand(s), cause(s) of action,
damage(s), loss or expense (including court costs and reasonable attorneys
fees) of any kind or nature (“Liability”) which may arise out of, result from,
or relate to my participation in the Event, including claims for Liability
caused in whole or
in part by the
negligence of the Released Parties. I further agree that if, despite this
Agreement, I, or anyone on my behalf, makes a claim for Liability against any
of the Released Parties, I will indemnify, defend and hold harmless each of the
Released Parties from any such Liability which any may be incurred as the
result of such claim.
I hereby warrant that I have read this
Agreement carefully, understand its terms and conditions, acknowledge that I
will be giving up substantial legal rights by signing it (including the rights
of the minor, my spouse, children, parents, guardians, heirs and next of kin,
and any legal and personal representatives, executors, administrators,
successors and assigns), acknowledge that I have signed this Agreement freely
and voluntarily, without any inducement, assurance or guarantee, and intend for
my signature to serve as confirmation of my complete and unconditional
acceptance of the terms,
conditions and provisions of
this Agreement. This Agreement represents the complete understanding between
the parties regarding these issues and no oral representations, statements or
inducements have been made apart from this Agreement. If any provision of this
Agreement is held to be unlawful, void, or for any reason unenforceable, then
that provision shall be deemed severable from this Agreement and shall not
affect the validity and enforceability of any remaining provisions.
NAME OF PARTICIPANT (PRINT)________________________AGE:
___ DATE OF BIRTH: _____/_____/_______
SIGNATURE OF PARTICIPANT:
___________________________________________DATE:_____________________
Parental Consent (required if the participant is less than 18
years of age) As the Parent and/or Legal
Guardian to the minor identified above, I hereby accept and agree to all of the
terms and conditions of this Agreement on behalf of the minor in connection
with the minor’s participation in the Event(s). If, despite this Agreement, I,
or anyone on the minor’s behalf, makes a claim for Liability against any of the
Released Parties, I will indemnify, defend and hold harmless each of the
Released Parties from any such Liabilities which any may be incurred as the
result of such claim.
NAME OF PARENT/LEGAL GUARDIAN (PRINT): ______________AGE: ____
DATE OF BIRTH: ____/____/________
SIGNATURE OF PARENT/LEGAL GUARDIAN:
___________________________________DATE:__ _____________