Team Name:
Name of Team Captain:(first and last name)
Contact Email:
Address:
City:
State:
select
Alabama
Alaska
Arizona
California
Colorado
Connecticut
Delaware
Dist. of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Phone (day):
Phone (eve):
Shirt Size:
select one
Small
Medium
Large
X-large
Age:
Name of Team Member 2:(first and last name)
Email:
Phone:
Shirt Size:
select one
Small
Medium
Large
X-large
Age:
Name of Team Member 3:(first and last name)
Email:
Phone:
Shirt Size:
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Small
Medium
Large
X-large
Age:
Name of Team Member 4:(first and last name)
Email:
Phone:
Shirt Size:
select one
Small
Medium
Large
X-large
Age:
AC2012 is a fund raising event. Rotary supports local, regional and international causes.
Each team competes for a not-for-profit organization of its choice. The team may indicate this by naming their agency or it can leave it up to the Rotary Club Amelia Island Sunrise to donate the winnings to a worthy not-for-profit organization.
Check this box if your team would like Rotary-Sunrise to pick a not-for-profit agency
or Name the not-for-profit agency of your team's choice
Contact info of the agency picked by your team:(Phone, address, email)
WAIVER: in consideration of the acceptance of this application, I (we) the undersigned intending to be legally bound hereby, for myself and anyone on our team, release any and all claims for damages we may have against Rotary, Amelia Challenge 2012, the event organizers, directors, volunteers and any sponsors and their representatives, successors, and assigns for any and all injuries and death suffered by me or any of my team members in said event. I (we) attest and verify that I (we) know that a bicycling event as well as a walking/running event can be a potentially hazardous activity. I (we) acknowledge that participating in this event is inherently dangerous. I and my team fully realize the dangers of participating in this event, and fully assume the risk associated with such participation. However, we have sufficiently trained for the completion of this event and know that we are participating at our own risk. We understand that there may be unknown and unforeseeable hazards. We agree to abide by the rules and conditions laid down for the event and to follow instructions issued by event officials. We understand that circumstances beyond the control of the event director may cause the event to be modified, postponed or relocated. We agree that our names or pictures may be used by Rotary for promotional purposes. I (we) affirm that all the information on this entry form are true. We have read this waiver of liability and accept the risks and responsibility associated with entering this event. We hereby grant permission for the free use of our names and pictures in any broadcast brochure, website , or account of this event.
Team Captain Signature:
Team Member 2 Signature:
Team Member 3 Signature:
Team Member 4 Signature:
Todays Date:
*Note that your application is only valid once we receive your application fee.
