ENTRY FORM & WAIVER

All participants must complete an entry form and liability waiver form. Either print this page or use the pdf entry form and pdf liability waiver.

HEART OF THE SOUTH, ENTRY FORM

April 3, 4 and 5, 2009. Birmingham, Alabama

Name _______________________
Address _________________________________________
Phone _______________________RAMM Qualified_________
Email ______________________________
Male____ Female_______ Age_______ T Shirt Size_________

Category
Solo 500 Mile________ $200
Solo 200 Mile________ $50
Tandem________ $250

Teams
Each Member on the team must submit a form and please give name of team.
Two Person Team______ $300 Total
Four Person Team______ $400 Total
Team Name_________________________________________

All entrants must be members of the UMCA, the website for membership is, http://www.ultracycling.org.

Please include check or money order payable to “Athletes for Charitable Causes” (note for HOS 500 or 200), for applicable fees with this application. 50% of your fee is deductible on taxes, ACC is a registered 501-C-3. Also include signed waivers for entrants and crew members, forms at www.heartofthesouth500.com.

Mail to Heart of the South 500, PO Box 430094, Birmingham, Alabama, 35243

Tom Robertshaw, director. rfamile@bellsouth.net, 205.969.0463

HEART OF THE SOUTH 500/200
Release of Liability/Agreement to Terms and Conditions
(this form may be copied)
Each person involved in the HOS 500/200 as rider, crew, or official must complete form.

In consideration of the acceptance of my participation as a rider, support crew member, film crew, media person, or official in the HOS 500/200 organized by ATHLETES FOR CHARTIBLE CAUSES I hereby waive, release, and forever discharge any and all rights and claims for damages, for death, personal injury, or property damage which I may incur, or which may hereafter accrue to me as a result of my participation. This release is intended to discharge in advance ATHLETES FOR CHARITABLE CAUSES, the sponsors, the officials, any involved municipalities or other public entities (and their respective agents and employees), the Board of Directors and Officers of the UltraMarathon Cycling Association, Inc., and the following individuals: Thomas S. Robertshaw, from and against any and all liability arising out of or connected in any way with my participation in said event, even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above.

I further understand that it is possible for serious accidents to occur during bicycle racing to anyone connected or not connected with the event, and that a rider, support crew member, official, or anyone could conceivably be injured by a cyclist, person, or criminal action, other vehicle, or acts of nature like tornadoes, rain, heat, cold, or any other injury-producing situation, and sustain mortal or serious personal injuries, and/or property damage, as a consequence thereof. Knowing the risks of ultra-marathon bicycle racing, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence or carelessness) might otherwise be liable to me (or my heirs or assigns) for damages. I have read, understood, and agree to abide by the rules of event as published by ATHLETES FOR CHARITABLE CAUSES It is further understood and agreed that if I violate any of the rules of the event, I, or the rider I am supporting, can be disqualified. I understand that all motorized vehicles used in the event must have the minimum legal requirements of property damage and bodily injury liability automobile insurance for the state of registration. I also understand and agree that any record of my participation in this event, be it photographic, electronic, or otherwise, can be used to promote the HOS 500/200 and/or appear on merchandise to be sold.

I further understand that in the process of cycling in this event on public highways in a competitive situation, it is possible that some traffic conditions can become very congested and dangerous for driving or cycling. I realize that I am ultimately responsible for my own safety and I will not hold the ATHLETES FOR CHARITABLE CAUSES or any of the individuals or entities listed above responsible for anything that could happen to me or a member of my support crew.

Signature _______________________________________
Date ________________
Printed Name _________________________
Birthdate mm ____dd____yy____
Address _______________________________
City _______________________________ State/Prov. _____
Postal Code _______________
Country _______________________________
T Shirt Size________________
Phone _______________________________
E-mail _______________________________
Signature of Parent (if under 18) _____________________________
Your role in HOS 500/200 (circle)  Rider   Crew   Official
If crew, Name of Rider or team you are supporting

_____________________________