SWISS CHEESE & SPOTTED COWS (SCSC) BICYCLE TOUR 2017

REGISTRATION FORM

Please complete the information below and mail with payment to:

Derks Cycle Tours

748 Iowa Ave W

St. Paul, MN 55117

Name (first, last): ______

Street Address: ______

City: ______State: ______Zip: ______

Phone #: ______Email address: ______

Emergency Contact Name and phone #: ______

Gender: Male___ Female ___Date of birth: ______(all participants must be 16 years or older)

Type of bicycle you will be riding: road _____ hybrid ______mountain ______recumbent ______

Tandem ______Other (please specify): ______

Room preference:

_____ Two beds. Please pair me with a same sex roommate*

_____ Two beds. Please pair me with (roommate name) ______

_____ One bed. Please pair me with (roommate name) ______

_____ Single Occupancy Room ($210 single supplement fee)

* If you don’t have a roommate but are willing to share a room with another person of the same gender, we will attempt to find a roommate for you. If a suitable roommate cannot be found, we will notify you 45 days prior to the trip date. You can then either opt to cancel your reservationwith a full refund or pay the single supplement fee.

Pricing:

Description / Cost / Total Cost
SCSC Tour Fee** – double occupancy / $835
SCSC Tour Fee ** – single occupancy / $1,045
Registrations received by Feb 28, 2017 receive a FREE moisture-wicking shirt. Specify your size below:
Womens: XS S M L XL XXL
Mens: S M L XL XXL XXXL
Jerseys:
Womens short-sleeve: XS, S, M, L, XL, XXL / $60
Womens sleeveless: XS, S, M, L, XL, XXL / $60
Womens vest: XS, S, M, L, XL, XXL / $60
Unisex short-sleeve: S, M, L, XL, XXL, XXXL / $60
Unisex sleeveless: S, M, L, XL, XXL, XXXL / $60
Unisex vest: S, M, L, XL, XXL, XXXL / $60
TOTAL

**Tour fee includes five nights lodging (Sat-Wed), 4 breakfasts (combination of hot & continental), 4 dinners, Swiss entertainment in New Glarus, farm tour, brewery tour, baggage transport to each night’s destination, maps, and SAG & mechanical support. All other fees are on your own.

SWISS CHEESE & SPOTTED COWS (SCSC) BICYCLE TOUR 2017

Waiver and Release - Read Carefully - This is a contract with legal consequences.

I, the undersigned, know that bicycle tours are potentially hazardous events, and attend them out of my own free will and choice. In choosing to attend the Swiss Cheese and Spotted Cows bicycle tour and any related events or activities, I fully accept and assume all risks, whether before, during or after the event and related events or activities. These include, without limitation, risks of physical injury, mental injury, emotional stress, trauma, death, contact with other participants, equipment failure, inadequate safety equipment, the effects of weather including extreme temperature or conditions, traffic, contact with motor vehicles of all types and descriptions, collision with other riders or fixed objects, the conditions of the road, theft, camping, and participating in events or activities along the route. All risks are known and appreciated by me. I waive any and all specific notice of the existence of risks. I agree that leaders and maps are provided for my convenience only and not to guaranty a safe route or trip. I shall assume and pay my medical and emergency expenses in the event of injury, illness or other incapacity regardless of whether I authorized such expenses. I realize that bicycle touring requires physical conditioning and I represent that I am in sound medical condition capable of participating in the ride without risk to myself or others. I have no medical impediment that would endanger myself or others. I understand that situations may arise during bicycle tours that may be beyond the control of sponsors, promoters and organizers. I will be solely responsible for the condition and adequacy of my bicycle, safety gear and riding equipment. I will ride safely within the limits of my own abilities, my equipment and the riding conditions and in a manner so as not to endanger myself or others. Knowing these facts and in consideration of my nonrefundable entry, acceptance, admission to and participation in this tour and its related events and activities, I, for myself and anyone acting on my behalf, waive, release, discharge, indemnify, covenant not to sue and agree to hold Swiss Cheese & Spotted Cows, Mary Derks, Derks Cycle Tours LLC, all other sponsors and participating clubs, communities, school districts and organizations, event officials, emergency and support personnel, volunteers and their representatives, and the officers, directors, employees, representatives, agents, insurers, insurance brokers and successors of all of the above, harmless from any and all claims, demands and actions of any and every kind that I have, may have or may hereafter accrue against the released parties, directly or indirectly, arising out of or relating in any respect to my attendance or participation in this event and its related events and activities, including, without limitation, litigation expenses, attorney fees, loss liability, damages or costs. My waiver and release of all claims, demands, actions and liability shall include, without limitation, any injury, damage or loss to my person or property which may be caused by any act, or failure to act, by the above-identified persons and entities or sustained by me before, during or after this event and its related events and activities. I agree to abide by all event rules and regulations. I waive my rights of privacy or publicity and grant permission to all of the foregoing to use any photographs, motion pictures, videotapes, recording or other record of this event for any legitimate purpose. I further agree to indemnify and hold the parties released above harmless from any and all losses, damages, claims and expenses, including attorneys fees, arising from or relating in any respect to my participation in this event or its related events and activities. If I am a minor my parent or guardian is also signing on my behalf and we both agree to be bound by the terms of this agreement, waiver and release. If I am the parent and/or legal guardian of a minor participant, I certify that the minor is in good health, qualified and in proper physical condition to participate in this event and I hereby release, discharge, covenant not to sue, and agree to indemnify and save and hold harmless all of the above released parties from all liability, claims, demands, losses or damages on the minor’s account incurred in connection with this event or its related events and activities. I will indemnify, save and hold harmless each of the released parties from any litigation expenses, attorney fees, loss liability, damage or cost that may occur as the result of any such claims in connection with the minor’s participation in this event and its related events and activities.

______

Signature(Signature of parent or guardian if 17 or under) Date

WAIVER MUST BE SIGNED or registration will be returned.