LAMBERT AIRPORT ROTARY CLUB
ST. LOUIS COUNTY, MISSOURI - USA - DISTRICT 6060

Pedal to End Polio Registration Form

Print a form for each rider (½" margins all around)

 

Rider Name: ____________________________________________________

Address: _______________________________________________________

City: ___________________________ State: ______ Zip: ________________

Home Phone: __________________Rider Work Phone: __________________

Rider's E-Mail: __________________________________________________

In consideration for being allowed to participate in the ride, the participant agrees as follows:

ASSUMPTION OF RISK/RELEASE AND WAIVER OF LIABILITY:

Each individual participating in the bicycle ride (hereafter "participant") hereby acknowledges
he/she assumes the risk of any injury to person or property arising from the ride. Each participant
hereby waives, releases and covenants not to bring any claim against Lambert Airport Rotary
Club and their respective officers and volunteers (all collectively referred to herein as the "charities")
from any loss or damage, and any claim or demands, on account of injury or death to the participant
or injury to property of the participant, whether caused by the negligence of charities or otherwise,
arising from the participant’s participation in the ride, and that this agreement shall be binding upon
the participant and his/her heirs, next-of-kin, personal representatives, successors and assigns.

OBEY ALL APPLICABLE LAWS:

Each participant hereby represents and agrees that he/she will obey all state, federal, county and
municipal laws during the ride and will wear all minimum safety apparel as required by state law
during the ride.

Signature of Rider Date ________________________________________________________

Parent or legal guardian must sign on behalf of any rider under 18 years of age. If the parent or legal guardian is not
present on the ride date, the parent or legal guardian’s signature agreeing to the foregoing provisions must be notarized
on this form].

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Last Update on 09/14/2010