registration

JOIN THE TEAM
for the
6th Annual Racin’ 4 Mason Cycling Fundraiser
SUNDAY, JULY 19, 2015
NAME: _____________________________________ DOB________ [ ] M [ ] F
ADDRESS: _________________________________________________________
Street
_________________________________________________________
City
State
Zip
PHONE: ___________________________________________________________
EMAIL ADDRESS: ___________________________________________________
EMERGENCY CONTACT: _____________________________________________
EMERGENCY CONTACT PHONE: ______________________________________
Are you a member of a cycling club or organization?
[ ] Yes
[ ] No
If yes, which one:
JERSEY SIZE: _____
SOCKS: ____
XS to 4XL
M, L, XL
ROUTE: ____________
Southern, 72.5-mile point to point
Northern, 16.2-mile Camp Loop
72.5-mile South Ride has 3 wave roll outs, all starting from 117 Van Dyke Road, Hopewell, NJ 08525.
Please check which wave you will participate in:
[ ] WAVE 1: 14 MPH rolls out at 7:15 am.
[ ] WAVE 2: 16 MPH rolls out at 7:45 am.
[ ] WAVE 3: 18 MPH rolls out at 8:10 am.
16.2-mile North Loop Ride starts promptly at 11 am from YMCA Camp Mason.
Return transportation provided from Camp Mason to Hopewell. Full Sag Support, Barbecue Lunch &
optional swim in the Camp pool provided for both groups. $120 entry fee supports the YMCA Camp
Mason Campership Program.
RACIN’ 4 MASON PAYMENT INFORMATION
Please return information form, waiver (on next page) and payment to:
YMCA Camp Mason 23 Birch Ridge Road, Hardwick, NJ 07825
Entry Fee of $120
[ ] Check (please make checks payable to YMCA Camp Mason)
[ ] Visa
[ ] MasterCard [ ] Discover [ ] AMEX
Credit Card Number ____________________________________________________________________
Exp. Date __________ Security Code ______ Name on Card __________________________________
Signature ____________________________________________________________________________
Liability Waiver Form & Ride Rules
To the best of my knowledge, I am in good physical condition and fully able to participate in this course.
I am fully aware of the risks and hazards connected with the participation in this event, including physical
injury or even death, and hereby elect to voluntarily participate in said event, knowing that the associated
physical activity may be hazardous to me and to my property.
I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY
DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or loss or
damage to property owned by me, as a result of participation in this course.
I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE YMCA Camp Ralph S.
Mason, its professional staff (seasonal and full time), Board of Trustees, volunteers, Racin’ 4
Mason event organizers, event staff & supporters to this event from any and all liability, claims,
demands, action and causes of actions whatsoever arising of or related to any loss, damage or injury,
including death, that may be sustained by me, or to any property belonging to me, while participating in
physical activity, on the cycling route, or while on or upon the premises (YMCA Camp Mason) where the
event is being conducted as it pertains to the Racin’ 4 Mason cycling event of 2015.
It is my expressed intent that this release and hold harmless agreement shall bind the members of my
family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased,
and shall be deemed as a RELEASE, WAIVE, DISCHARGE, and CONVENTION TO SUE the above
named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement
shall be constructed in accordance with the laws of the State of New Jersey.
In signing this release, I acknowledge and represent that I HAVE READ THE FORGOING Waiver of
Liability and Hold Harmless Agreement, UNDERSTAND IT AND SIGN IT VOLUNTARILY as my own
free act and deed; no oral representations, statements or inducements, apart from the foregoing written
agreements have been made and I EXECUTE THIS RELEASE FOR FULL, ADEQUATE AND
COMPLETE CONSIDERATION FULLY INTENTING TO BE BOUND BY SAME.
Signature _____________________
_________________________________
Print name ____________________________________________________________________
Date ______
Event: Racin’ 4 Mason 2015
Ride Rules
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All riders are required to check in prior to the ride, and sign a waiver.
This is a RIDE, not a race.
The roads are open to vehicular traffic; all rules of the road must be obeyed.
Participants are responsible for their own safety.
Helmets are required to be worn at all times participants are on the bike.
Participants should ride in a safe and courteous manner; please stay to the right, except when
passing.
You will be riding on country roads; assume there is gravel at every turn. Be aware that some
sections of roads are rough and that road surfaces vary.