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Release Applicant For Bicycle Racing License

(With Consent of Parent or Guardian or Minor)

I wish to be a licensed athlete under the constitution, bylaws and racing rules of the (name of cycling authority). I certify that the information on this application, as entered by me, is truthful.

I acknowledge that cycling is an inherently dangerous sport in which I participate at my own risk and that the (name of cycling authority) is a (nonprofit corporation or otherwise as the case may be) formed to advance the sport of cycling, the efforts of which directly benefit me. In consideration of the agreement of the (name of cycling authority) to issue a racing license to me, I, on behalf of myself, my heirs, assignees and personal representatives, hereby release and forever discharge the (name of cycling authority), its employees, agents, members, sponsors, promoters and affiliates from any and all liability, claim, loss, cost or expense, and waive and promise not to sue on any such claims against any such person or organization, arising directly or indirectly from or attributable in any legal way to any negligence, action or omission to act of any such person or organization or execution of any bicycle racing or sporting event, including travel to and from such event, in which I may participate as a rider, team member or spectator.

I currently have no known physical or mental condition that would impair my capability for full participation as intended or expected of me except for (enumerate).

Dated:

Signature

Full Name

AGREEMENT & CONSENT OF PARENT OR GUARDIAN OF MINOR

I, as parent or guardian of the above applicant, represent to the (name of cycling authority) that the facts herein concerning my child or ward are true. I hereby give my permission for my child or ward to enter any bicycle race or event sanctioned by the (name of cycling authority) during the period of the license applied for, and further, in consideration of the granting of such license, agree individually and on behalf of my child or ward, to the terms of the above agreement and release of liability.

Signature of Parent or Guardian

Acknowledgment

STATE OF -------)

) ss: [date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

[signature]

[Name of Notary Public]

My commission expires: [date]

(Seal)