1. Healthcare

2015 Fiesta Wildflower
April 26, 2015 - 8:00 AM
Held under USA Cycling Permit
San Antonio, TX
(100 mi, 100 Km, 40 mi, 25 mi, 15 mi routes)
www.fiestawildflower.com
Last Name _________________________________ First Name ________________________________
AGE _________ Date of Birth (mm/dd/yyyy) _________/_____/________
Parent/Guardian Name if under 18 yr _____________________________________________________
Address ____________________________________________________________________________
City __________________________________ State ____________ Zip Code ___________________
Phone # ________________________________
cell or home
Email address _____________________________________________________________________
Emergency Name Contact _________________________Emergency Phone # ___________________
T-Shirt size -- circle one
Ride Distance -- circle one
Youth -- S M L
100 Miles
Adult -- S M L XL XXL
100 Kilometers
40 Miles
25 Miles
15 Miles
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Mandatory Fee Schedule**: Fiesta Wildflower Bike Ride – Sunday, April 26, 2015 (8:00am)
Register Feb 1, 2015 - Mar 31, 2015
$ 55.00
$________
Register Apr 1, 2015 - Apr 26, 2015
$ 65.00
$________
$ 10.00
$________
$ 80.00
$________
Optional Items:
Extra Fiesta Wildflower T-Shirt
(Extra) T-Shirt size -- circle one Youth -- S M L
Adult -- S M L XL XXL
2015 Wildflower Jersey
(Circle size) S - M - L - XL - XXL
TOTAL DUE
$________
**Please note that a $5 admin fee has be added to ALL paper entry forms and is reflected in the above fee schedule.**
Credit Card # __/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/
Expires __/__
CVV# __/__/__
PRINT Name on Card ________________________________Signature _____________________________
(Credit cards will be processed through Britton’s Bicycle Shop)
See www.fiestawildflower.com for complete event details. Please contact the race director at [email protected] for any addtional
information needed. Please make checks payable to HCSA and mail entry form to HCSA Race Director, 434 N SL, 1604 W #1109, San
Antonio, Texas 78232. Enclose a self addressed stamped envelope for verification of entry if desired.
THE WAIVER ON THE BACK (page 2) MUST BE SIGNED BEFORE YOUR ENTRY WILL BE PROCESSED.
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For race director use only:
Race # ____________________postmarked ______________cash/check/credit card ___________________
(Fiesta Wildflower Release)
Fiesta Wildflower Release
THIS WAIVER IS A CONTRACT WITH LEGAL CONSEQUENCES. PLEASE READ CAFEFULLY BEFORE SIGNING. YOU
CANNOT PICK UP YOUR PACKET OR PARTICIPATE WITHOUT A SIGNED RELEASE.
In consideration of the acceptance of my entry in the Fiesta Wildflower, I hereby acknowledge that I am assuming risks and agree to indemnify, not
to sue and release from liability the Fiesta Wildflower and Hill Country Sports Association (HCSA) its employees, volunteers, members, board,
sponsors, promoters and affiliates (collectively releases) and that I am giving up substantial legal rights. I have read it carefully before signing and I
understand what it means and what I am agreeing to.
I fully realize the dangers of participating in a bicycle event and fully assume the risks associated with such participation including, by way of
example and not limitation, the following: the dangers of collision with pedestrians, vehicles, other riders, and fixed or moving objects arising from
surface hazards, equipment failure, inadequate safety equipment, weather conditions, and the releasee’s own negligence, the negligence of others and
the possibility of serious physical and/or mental trauma or injury associated with athletic cycling events.
I hereby waive release and discharge for myself, my heirs, executors, administrators, legal representatives, and successors any and all rights and
claims which I have or which may hereafter accrue to me against the Fiesta Wildflower and the HCSA, its employees, all volunteers and sponsors of
this event, organizers and any promoting organizations. Medical providers, property owners, law enforcement agencies, all public entities, special
districts and properties (and their respective agents, officials, and employees) through or by which the events will be held for any and all damages
which may be sustained by me directly or indirectly in connection with or arising out of my participation in or association with the event or travel to
or return from the event.
I understand that still and video images of me may be taken in conjunction with the Fiesta Wildflower and agree that they may be used to promote
the Fiesta Wildflower and sponsors.
I agree that it is my sole responsibility to be familiar with the ride course and special rules for the event. I understand and agree that situations may
arise during the ride, which may be beyond the immediate control of the ride officials or organizers and I must continually ride so as to not endanger
others or myself. I accept responsibility for the condition and adequacy of my equipment. I will wear a helmet certified by Ansi Snell. I have no
physical or medical condition that would endanger others or myself if I participate in this event. I agree for myself and successors that the above
representations are contractually binding and are not mere recitals. Should my successors or I assert a claim in contravention of this agreement,
my successors or I shall be liable for the expenses (including legal fees) incurred by the releasee in defending the claims. This agreement may not
be modified orally and a waiver or notification of any provision shall not be construed as a modification of any other provision herein or as consent
to any subsequent waiver or modification. I consent to the release by any third party to releasee and insurance carriers of my name and medical
information that relate solely to any injury or death I may suffer arising from this event. Every term and provision of this contract is intended
servable. If any one or more of them is found to be unenforceable or invalid that shall not affect the other terms and provisions which shall remain
binding and enforceable.
Weather Contingency: I fully understand and accept that the Fiesta Wildflower Ride is a rain or shine event. Should weather events dictate road
conditions are unsafe for cyclists ride distances may be shortened or rerouted. In the unlikely event that weather conditions require cancellation of
the event, all athletes will be provided with a $20.00 discount off the 2016 event. No refunds will be issued. The rider accepts full responsibility for
riding in all weather conditions that present themselves during the ride.
____________________________________
__________________________________
PRINT YOUR NAME
SIGN YOUR NAME
Date _______________
If under the age of 18, parents/guardian must sign below.
____________________________________
__________________________________
PRINT NAME OF PARENT/GUARDIAN
SIGNATURE OF PARENT/GUARDIAN
Fiesta Wildflower Release
Date _______________