Step Up For Soldiers Warrior Ride Form

First Name

MI

Last Name

Address

City

State

Zip

Work Phone

Home Phone

Email

Birth Date

Gender

Employer

Emergency Contact Name

Emergency Contact Number

Check the appropriate box: (43 mi.)(23 mi.)(5 mi. walk)

Are you a Veteran? If yes fee is $25: Veteran YesVeteran No

My Fundraising Goal Is: $

Release From Liability (for participant and family): In consideration of my participation in the Warrior Ride 2010, I hereby agree on behalf of myself , my heirs, legatees, executors, administrators, and personal representatives, to release the organizers and volunteers involved in the planning, organizing and operation of the Warrior Ride 2010 from liability for injury to me or my property caused by their negligence. I intend that the effects of this releaseshall be to release such organizers and volunteers from any liability to me arising from their failure, in any way, to use reasonable care in their activities pertaining to the Warrior Ride 2010. If I am under the age of eighteen years, then this release shall be signed on my behalf by my parents or guardian.

If I am injured, I hereby authorize local medical facilities to disclose my individually identifiable health information as it pertains to any care received in conjunction with Warrior Ride 2010 event on October 9, 2010. This information will be released to the Medical Director of the Warrior Ride 2010 so he can notify family members of my location and status and also monitor and evaluate safety conditions for the event. Individually identifiable information will not be kept by the Warrior Ride 2010 management beyond the end of the event. This authorization expires on October 14, 2010.

By signing this release, I acknowledge that all riders are required to wear an ANSI– and/or Snell approve helmet during the entire ride, and all participants are encouraged to wear light bright, or reflective clothing. I hereby give my full permission for the use of my name and photograph in connection with the event.

I HAVE READ AND FULLY UNDERSTAND THE FOREGOING RELEASE AND INDEMNITY.