REGISTRATION & MEDICAL FORM

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1 REGISTRATION & MEDICAL FORM NAME ADDRESS CITY PROV POSTAL TELEPHONE CLUB BIRTH DATE DD/ MM / YYYY AGE (on Dec. 31, 2011) GENDER: M F MB MEDICAL # For Office Use Only: Plate number: Category: Amount Paid $ Payment Method PROGRAM FEE: $120 includes MCA/CCA license and insurance, coaching and all KOM event entry fees. For families with more than one child in KOM, $5 for each additional child residing at the same address will be refunded by the local club. Payment accepted: Cash, Cheque or Money Order payable to: The Manitoba Cycling Association Please circle the appropriate response below pertaining to your child: Yes No Previous history of concussions? Yes No Fainting episodes during exercise? Yes No Epileptic? Yes No Wears Glasses? Yes No Are lenses shatterproof? Yes No Hearing problem? Yes No Asthma? Yes No Trouble breathing during exercise? Yes No Heart Condition? Yes No Diabetic? Yes No Has had an illness lasting more than a week in the past year? Yes No Takes Medication?

2 Yes No Allergies? Yes No Wears a Medic Alert Bracelet or Necklace? Yes No Surgery in the last year? Yes No Has been in hospital in the last year? Yes No Has had injuries requiring medical attention in the past year? Yes No Presently injured? Please give details below if you answered Yes to any of the above items. Medications: Allergies: Medical Conditions: Recent Injuries: Last Tetanus Shot: Yes No Date: Any information not covered above: In case of medical emergency, I understand that every reasonable effort will be made to contact myself. In the event that I cannot be contacted, I hereby give permission to all organization personnel to act in my name and to secure proper medical treatment for my child. Date: Telephone: Cell Phone #: Name (Print): Signature: Alternate/Emergency Contact Information: Emergency Contact Name: Emergency Contact Telephone #: Relation to Child:

3 WAIVER, RELEASE & INDEMNITY I understand and agree that my participation in events, programs, races, or activities organized, operated, conducted and/or sanctioned by the Canadian Cycling Association and/or Provincial Associations and Various CCA Clubs and Members registered with CCA is conditional upon my execution of this document. 1. I am aware that cycling, and in particular competitive cycling, endurance and BMX racing, involves the possibility of injury or death. 2. I accept these risks, and all others arising from these events and programs, even if arising from the negligence, gross negligence or negligent rescue by those associated in any way with the Canadian Cycling Association events and programs I may be involved in, the venues at which these events and programs takes place or by those organizing, officiating, or participating in these events and programs throughout the year, including their respective officers, directors, employees, agents, servants, volunteers and repr 3. I understand that all applicable rules for participation must be followed and that SOLE RESPONSIBILITY FOR MY PERSONAL SAFETY REMAINS WITH ME, including my physical and emotional preparation and fitness to participate in all events and programs throughout the year. 4. I undertake and agree to remove myself from participation if I sense or observe any unusual hazard or unsafe condition, or if, at any time, at any event or program, I feel unable or unfit to safety continue for any reason. 5. I give, a FULL RELEASE AND WAIVER OF LIABILITY AND ALL CLAIMS that I have, or may have in the future, against Canadian Cycling Association, and all other Releasees from all liability for any loss damage, injury or expense that I may suffer as a result of my participation in any part or parts of the events or programs or my presence at any venue at which they may take place, due to any cause whatsoever including the forms of negligence set forth in paragraph 2 above or from any breach of contract or statutory duty or other duty of care including any duty of care owed under the relevant on the part of the Releasees. 6. I AGREE NOT TO SUE and I further agree TO INDEMNIFY AND SAVE HARMLESS the Releasees from all expenses, fees, liability or damage award or cost of any type whatsoever arising from my participation in these events or programs. PARENTAL CONSENT FOR MINOR PARTICIPANT and INDEMNITY AGREEMENT I have read and understood the above waiver, release and indemnity, and have discussed the same with the minor person signing above. I am satisfied the said minor understands the waiver and release and his/her obligations as set out. In consideration of the participation of my minor child/ward I too agree to waive, release and indemnify the Releasees in the terms set out above. I am aware that by signing this agreement I am waiving substantial legal rights, which my minor child/ward and I, our respective heirs, executors, administrators and next of kin may have against the Releasees. SIGNATURE: DATE:

4 Online Registration Go to the Manitoba Cycling Association website at Follow the Online Registration link on the right side of the home page for MCA Registration and Sign up This will direct you to Karelo.com Log on to Karelo (If you have not created a profile before, do so before proceeding) Under Manitoba Cycling Association 2011 Online Membership Application click Sign Up now o The Registrants Name will be you, you must select gister your child in the program Fill in Membership Information which includes: birthrate, gender, club, membership type o Affiliated club: Kids of Mud o Kids of Mud Club: Club of your choice o Membership type: Kids of Mud ($120) You must select Age Group and Ability for each Discipline (Age as of Dec 3 1st, 2009) KOM participants will only be riding in XC (Cross Country) Continue down that page and check the appropriate boxes. Complete the to continue with your payment or press Add Person to register an additional person (additional child)

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