Capital-City-registration-form

Please provide additional registration information on a separate sheet of paper. For non-riders, please call or email us. You will find the cancellation policy after the registration page & just before the waiver text.

____________________________________________________________________________________M/F (circle) Age________

First name Last name

_____________________________________________________________________________________________________________________________

Street City State Zip

_____________________________________________________________________________________________________________________________

Home Phone Cell Phone Work Phone

_____________________________________________________________________________________________________________________________

Emergency Contact & Phone Your Email

Roommate:

Do you need PAW to help you find a roommate? YES____ NO____

If you have a roommate, please provide name here: _____________________________________________________

Please Note:

If you cancel and leave your roommate without a replacement, you’ll need to pay the private room fee, explained in the cancellation section below.

If this is your first tour with Pedal Across Wisconsin, how did you hear about us?

_____Friend: Name: _______________________________________________Bike Club____________________________________________

_____ Internet:Website _____________________________________________ Other _______________________________________________

_____________________________________________________________________________________________________________________________

FOR PAW USE ONLY:

Deposit: $_____________ # _________ Balance: $ _____________

Roommate: ____________________________________________

Date added: _____________________

TOUR FEES

#_____ Adults: $695.00 Includes motel Sunday thru Friday, (assumes two

persons/room. For private room, add $285.00), 3 dinners,

2 continental breakfasts, 4 full breakfasts, baggage, maps,

emergency support, on-road food stops, Happy Hours, and parking. $____________

#_____ Adults: Pre-ride Room, Saturday 6/8 @ Sheraton-Madison

@$48.00/person, assumes 2 persons/room. For one person, rate=$96.00

$____________

Includes full breakfast Sunday morning

WINDSHIRT: 100% microfiber, the new high-tech materials that breathes going up hill better than you do. Machine washable with wrist and waistbands for extra comfort. Long-sleeved. Carolina Blue

Size: S M L XL 2X Quantity: _____ @ $20.00 each $____________

TEES: Lightweight, cotton blend, high-visibility safety yellow & blue.

Longsleeve: Size: S M L X L 2X Quantity: _____ @ $15.00 each $____________

Shortsleeve: Yellow-Size S M L XL 2X Quantity: ______@ $10.00 each $____________

Shortsleeve: Turquoise-Size S M L XL 2X Quantity: ______@ $10.00 each $____________

TOTAL TOUR FEES $____________

DEPOSIT ENCLOSED (Minimum 50% of total tour fees) $____________

BALANCE DUE by May 2nd $____________

Cancellation Policy per person:

Through April 30th: $60.00

After April 30th, the maximum refund will be equal to the total returned by motels and restaurants to PAW.

NOTE: If you have a roommate, the private room fee of $265 (plus $48 for pre-room) will be assessed, in addition to these cancellation fees, if no replacement can be found.

Please complete registration form, read and sign waiver, and enclose minimum 50% deposit. Checks should be made out to: Pedal Across Wisconsin, Inc. Sorry, we do not take credit cards.

If you have any questions, please contact Dr. J. Pedal at 847-707-6888 or email him at [email protected]

Pedal Across Wisconsin, Inc. Release and Waiver of Responsibility

In signing this release, I acknowledge that I understand the nature of the Pedal Across Wisconsin, Inc. tour (‘activity’) and that it is a potentially hazardous event, and attend it of my own free will and choice. In choosing to attend Pedal Across Wisconsin, Inc.’s activity and any related events or activities, I fully assume all risks, whether before, during or after the Pedal Across Wisconsin, Inc. activity or related activities. These include, without limitation, collision with pedestrians, vehicles, other riders, sponsors, promoters, or drivers, and dangers arising from falls, camping, theft, road surface, equipment failure, inadequate safety equipment, weather conditions, as well as the possibility of physical and/or mental trauma, mental injury, emotional stress, serious bodily injury resulting in disability, death and paralysis.

I realize Pedal Across Wisconsin, Inc. activities require physical conditioning, and I represent myself that I am in sound medical condition, capable of participating without risk to myself and others. I have no medical impediment that would endanger myself or others. I waive any and all specific notices of risks. I agree that maps, directions, leaders and road markings are provided for my convenience only, and not to guarantee a safe route or trip. I understand and agree that a situation may arise during the Pedal Across Wisconsin, Inc. activity which may be beyond the control of the sponsors, promoters, or organizers, and agree to participate so as not to endanger myself and others.

I understand that any route or activity chosen as part of our outdoor adventure may not be the safest, but has been chosen for the interest or challenge provided. I understand the route requires bicycling on public roadways, and in bad weather, and that cyclists have been hospitalized and/or killed because of accidents that are either their responsibility or the responsibility of someone else. I further agree that I will bear and assume all expenses incurred in any accidents, illness, or loss of any kind. I further agree and warrant that if, at any time, I believe conditions to be unsafe, I will immediately discontinue further participation in the activity. I hereby consent to and permit emergency treatment in the event of injury, illness or death.

I give full permission for use of my name and photograph, motion pictures, video tape, recording, written comments or opinions, or other records of this event for any legitimate purpose. Pedal Across Wisconsin, Inc. reserves the right to decline accepting or retaining any tour participant whose health or actions impede the operation of the tour, or welfare of other tour participants. An approved (ANSI or Snell or equal) helmet is strongly recommended for use by all participants while riding bicycles. I agree to the terms and conditions of the Pedal Across Wisconsin, Inc. cancellation policy. I park my vehicle at my own risk and acknowledge the safe-keeping of my bicycle as my responsibility.

I have read this agreement, fully understand all the terms it contains, and understand that I have given up substantial rights by signing it freely, and without any inducement or assurance of any nature, and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law, and agree that if any portion of this agreement is held to be invalid, the balance notwithstanding, shall continue to be in full force and effect. Any action to interpret or enforce it shall be brought in Kane County, in the State of Illinois.

The foregoing understood and agreed, I hereby release and waive any and all claims against Pedal Across Wisconsin, Inc. sponsors, workers, volunteers, organizations, schools, businesses, and any other parties connected with this event in any way (‘releasees’) singularly or collectively, and further hold harmless and indemnify such releasees from and against any liability, claims of negligence, misadventure, harm, loss, inconvenience, or damage hereby suffered or sustained as a result of participation in the Pedal Across Wisconsin, Inc. tour, or any other activity associated herewithin. Such release, waiver, hold harmless and indemnity shall apply to my own claims and/or claims of third parties, relating to my participation in this event. I waive, release, discharge for myself, my heirs, executors, administrators, legal representatives (including successors) any and all rights and/or claims which I have, may have, or may hereafter accrue to me against the sponsors and promoters of Pedal Across Wisconsin, Inc. or other sponsors or affiliated organizations and their respective agents, officers, and employees for any and all damagers, injuries or claims which may be sustained by me directly or indirectly arising out of my participations in Pedal Across Wisconsin, Inc.. I agree to abide by the rules of the road and certify that I will read the Pedal Across Wisconsin, Inc. safety letter when sent to me.

The undersigned acknowledges having read and agreed to the terms of the foregoing Release and Waiver of Liability agreement, and also acknowledges they have read the safety letter.

EACH PARTICIPANT MUST SIGN A SEPARATE WAIVER

_______________________________________________

Signature of Adult Participant Date

______________________________________________________

Printed Name

Or, the following signatures if rider is a minor (under age 18): Parent or guardian must be on ride.

______________________________________________________ ____________________________________________________

Signature of Minor Age* Date Printed Name of Minor/Date

______________________________________________________

Signatures of both parents (or guardian) Date

847-707-6888 | [email protected]