Conquer Alcatraz Program Registration

  Name:
 
  
  Address:
 
 
  
  Work Phone Number:
 

  Home Phone Number:
 

  E-mail:
 

  Please choose your clinic date:
  Saturday, May 24th, 2003 - 9:30am Sunday, May 25th, 2003 - 9:30 am

  Payment Method:
  Personal Check Money Order / Cashier's Check Paypal
  
  Average race speed:
  10-15 mph 16-18 mph 18-20 mph 20-22 mph 22-25 mph

  Ave training speed:
  10-15 mph 16-18 mph 18-20 mph 20-22 mph 22-25 mph

  Is this your first Tricalifornia Escape from
  Alcatraz triathlon?
  Yes No, I have completed 1 Alcatraz No, I have completed 2 Alcatraz races No, I have completed 3+ Alcatraz races
  

  How many years have you been cycling? 
  0-1 year 1-2 years 3-5 years 5+ years

  How many miles/hours per week do you         
  currently cycle?
  0-50 Miles 50-75 miles 100-125 miles 125-150 miles 150-175 miles 175+ miles

  Please read carefully before submitting.

  Waiver  

I acknowledge that training for and/or participating in multi-sport events, triathlon, duathlon, swimming, cycling, running or any other endurance sporting events is an extreme test of a person's physical and mental limits and carries with it the potential risks for serious bodily injury, death or property damage.  

I hereby assume the risk for participating in the training
and other multi-sport related activities.
I certify that I am physically fit, am sufficiently trained
for participation in this program and my physical condition has been verified by a qualified, licensed health professional.

Furthermore in return for my participation in this program,
I on behalf of myself, my heirs or hereby:

a) Waive, Release and Discharge,
Philip Casanta, Rachel Sears and Hypercat Racing,
their officers, directors, administrators, employees, consultants and agents from any and all claims, liabilities for personal injury, partial or permanent disability, of property,
damage, medical or hospital bills, theft or damage of any kind, illness, death or damages of any kind including economic loss which may in the future arise out of or relate to my participation in this training program. 

b) Agree Not to Sue any of the persons or entities mentioned above for claims, costs or liabilities that I have waived, released or discharged herein;

c) Indemnify, Defend, and Hold Harmless, the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.

I acknowledge that my statements on this application are true.

I hereby affirm that I am eighteen (18) years of age or older. I have read the document and understand and agree to the waiver.

Name Date

Submission of this form is agreement to above terms.