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ABOUT YOU - Please provide all applicable information

Name:                       
Address:                  
                                  
City:                          
State/Province:          ZIP/Postal Code:
Country:                  
Phone:        
E-mail:        
Nationality:
Birthdate:      Gender: Male Female
RUSA Nr:       Membership Pending
Other Org.:  
e.g. Audax UK

Emergency Contact:
Relationship:
E-mail:
Phone:
Distance: 1200km 1000km Recumbent Fixed Tandem, partner:
I will have personal support.  I have completed these 1200k's:

QUALIFICATION - List brevets you have ridden since January 1, 2018 to qualify for the 3CR or a 1200k from 2017. If you have ridden a higher-distance brevet to substitute for a lower distance or other agreed-upon substitute(s), note that under "Event Distance". If you are applying prior to full qualification, send an e-mail listing your remaining qualifying info when you've completed your qualification.

Distance Date Location Elapsed Time Certificate Nr. Event Distance
200km
300km
400km
600km
or 1000km+

WAIVER - In consideration of being permitted to participate in any way in the SANTA CRUZ RANDONNEURS, INC Activities:, I, for myself, my representatives, assigns, successors, and heirs represent and agree as follows: I acknowledge that this athletic event or Activity is an extreme test of a person's physical and mental limits and carries with it the potential for death, serious injury and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of athletes, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to athletics, but are also present for volunteers. I hereby assume all of the risks of participating and/or volunteering in this event. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault. I certify that I am physically fit, have sufficiently trained for participation in the event and have not been advised otherwise by a qualified medical person. I further acknowledge that the Activity will be conducted over public roads and facilities open to the public during the Activity and upon which the hazards of traveling are to be expected. If at any time I believe conditions to be unsafe I will immediately discontinue further participation in the activity. I acknowledge that this Accident Waiver and Release of Liability (AWRL) form will be used by the event holders, sponsors and organizers, in which I may participate and that it will govern my actions and responsibilities at said events. In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) Waive, Release and Discharge from any and all liability for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to me or my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: LOIS SPRINGSTEEN, WILLIAM BRYANT, SANTA CRUZ RANDONNEURS, RANDONNEURS USA, (RUSA), AUDAX CLUB PARISIEN, and RANDONNEURS MONDIAUX their directors, officers, employees, volunteers, representatives, and agents, the event holders, event sponsors, event directors, event volunteers; (B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made by other individuals or entitles as a result of any of my actions during this event. I hereby consent to receive medical treatment that may be deemed advisable in the event of injury, accident and or illness during this event. I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and or assigns. This AWRL shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I hereby certify that I have read this document; and, I understand its content. I understand that I have given up substantial rights by signing this AWRL and have signed it freely and without any inducement or assurance of any nature.

Additional Remarks:

Submit your info electronically by clicking here.

Remember that you must both submit your application data (this form) and payment to get a reserved rider spot.


Revised: February 1, 2018 © Copyright 2003-2018 Santa Cruz Randonneurs, Inc. except as noted otherwise.