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Official 2012 Hog Wild 100 Registration
Form April 21, 2012 Name:
_______________________________ email: _________________________________ Address:
ONLY PRE-REGISTRATION BY April 15th GUARANTEE’S
A T-SHIRT T-Shirt
Size: S [ ] M [
] L [ ] XL [
] XXL [ ] Courses:
100-Mile [ ] 62-Mile [ ] 35-Mile [ ]
10-Mile [ ] Pre-Registration
(By April 15th) - $30 After
April 15th and ride day registration - $35 Children
11 and under ride free (A $5.00 fee will be charged if eating lunch.) Make
checks payable to: United Hog Wild 100 Mail
to: United Way Hog Wild 100 PO Box 157 Winchester TN
37398. SORRY,
NO REFUNDS Please print
clearly One form per rider To
participate in the Hog Wild 100, the following must be read and signed in
blue ink below. Release and Waiver
Statement: In consideration of the
acceptance of my entry, I the undersigned participant, for myself, my family
members, heirs, administrators, personal representatives, successors, and
assigns herby fully release, discharge and hold harmless any sponsors,
owners, and operators of motor vehicles and officers, directors, employees,
volunteers, and lessors of any of the foregoing persons or entities from any
and all liability, whether resulting from negligence of any aspect of the Hog
Wild 100, whether a pre-ride, post-ride activity or the ride itself. I also expressly covenant with the
aforementioned persons and entities not to sue any such persons and entities
for any such activity, including the negligence of any such persons or
entities. I certify and represent by
my application for entry that my physical condition is adequate to
participate safely in the Hog Wild 100, and I hereby acknowledge that the
above persons and entities have no obligation to provide medical care and
have not undertaken the responsibility to do so. In the event that I receive medical care as
a result of a medical emergency, I hereby consent to such care and fully
release the person(s) providing such care from any and all liability, whether
resulting from negligence or otherwise.
I authorize and consent to volunteers or to persons employed or
contracted by Hog Wild 100 to use any
videotape, film, newsprint, written advertisement, or otherwise, or any
materials containing my name or picture.
I further release any sponsors and all persons acting under authority
from any claims I might have due to initial or subsequent publication of such
materials or photographs. I hereby
certify that I have fully read and understand the foregoing release, waiver
and covenant not to sue, and sign it voluntarily. I also agree to abide by all traffic laws
and to wear a helmet at all times during the ride. Signature:
_____________________________________________ Date:____________ Parent/Guardian
(if
rider is a minor):____________________________Date:____________ |