Tour de Gabriola Bicycle Ride Registration Form
Sunday, June 3rd, 09:30-10:30 start

check one:   [   ] Traditional Tour (27 kms; Gabriola Elementary School/Silva Bay Inn)
                          [   ] Junior Tour (6 kms; Twin Beaches Mall)
                          [   ] Peterson Tour (8 kms; Silva Bay Inn)

     Name:                                                                                                Age:                     

     Address:                                                                                                                         

     Telephone:                                                                                                                       

     Emergency Contact:                                                         Telephone:                              

=============================== DISCLAIMER =============================
RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY AGREEMENT
           WARNING! BY SIGNING THIS FORM YOU GIVE UP IMPORTANT LEGAL RIGHTS
The Primary Care Gabriola committee and volunteers are not responsible for any injury, loss or damage of any kind sustained by or caused by any person while participating in the Tour de Gabriola bicycle ride, including injury, loss or damage which might be caused by the negligence of the committee.
In consideration of the Rider's participation in the Tour de Gabriola, the Rider acknowledges that he (and, if applicable, Parent or Guardian) is aware of the possible risks, dangers and hazards associated with the Rider's participation in this bicycle ride, including the possible risk of severe or fatal injury to the Rider or others.
In consideration of the Primary Care Gabriola allowing the Rider to voluntarily participate in the Tour de Gabriola, the Rider (and, if applicable, Parent or Guardian) agree: TO ASSUME AND ACCEPT ALL RISKS; TO BE SOLELY RESPONSIBLE FOR ANY INJURY, LOSS OR DAMAGE which the Rider or any property may sustain; TO HOLD HARMLESS AND INDEMNIFY the Primary Care Gabriola Committee and volunteers, the Gabriola Health Care Society and the Gabriola Health Care Foundation from any and all liability with respect to any damage to the property of, or personal injury to, the Rider or any third party resulting from my participation in the Tour de Gabriola.

RIDER (print name): ___________________________________

RIDER signature: ______________________________________

==> if rider under the age of 18 please provide

Parent/Guardian (print name): ___________________________________

Signature of rider and/or Parent/Guardian : ___________________________________
========================================================================
DONATIONS      Please make cheques payable to the "Gabriola Health Care Foundation."
                  Anyone wishing a tax receipt will need to provide a current address with POST CODE.

by whom:                                                                                                        amount:                

cash
cheque
by whom:                                                                                                        amount:                

cash
cheque
by whom:                                                                                                        amount:                

cash
cheque
by whom:                                                                                                        amount:                

cash
cheque
by whom:                                                                                                        amount:                

cash
cheque
              ----- Use other side for more sponsors and details ------
__________________________________________________________________

For more information, please e-mail:   PrimaryCareGabriola@yahoo.CA

        or visit our website at http://members.shaw.ca/PrimaryCareGabriola


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