Velo Veneto Registration Form
Please read and complete the entire form carefully.
Mail with a $600 deposit made out to Pat Carroll
(cashiers check or money orders only) to:
Pat Carroll, 270 Talbot Ave., Santa Rosa, CA 95405
Each participant must complete a separate registration form
Name:_____________________________________________________________________________________________________
Address:___________________________________________________________________________________________________
City/State/Zip:______________________________________________________________________________________________
Phone (home):___________________________(work):_________________________ e-mail:______________________________
Birth Date:___________________________________ Birthplace:____________________________________________________
Passport Number:_________________________________ Date of Issue:______________________________________________
Place of Issue:____________________________________ Date of Expiration:__________________________________________
Emergency Contact:_____________________________________________ Phone:______________________________________
Address:_____________________________________________________________ e-mail:________________________________
Medical Conditions/Allergies:_________________________________________________________________________________
Dietary Restrictions:_________________________________________________________________________________________
Racing Profile
How many years have you been involved in competitive cycling? __________________
What category do you race in? ________________________
How many races have you won? __________ or placed? ____________
Name the races, if you wish ___________________________________________________________________________________
I feel my strengths as a racer are: (check all that apply)
___road racing ___criterium ___time trial ____strategy ___climbing ___endurance ___sprinting
I feel that my weaknesses as a racer are: (check all that apply)
___road racing ___criterium ___time trial ___strategy ___climbing ___endurance ___sprinting
My typical big week of training consists of _______hours or ________ miles
How did you hear about Velo Veneto?____________________________________________________________
Responsibility Agreement and Release
Velo Veneto, hereafter also referred to as “the camp”, requires that all persons participating in the bicycle racing camp (“the camp”) conducted by Velo Veneto sign this Responsibility Agreement and Release as a condition of their attendance and participation in the “the camp” and its activities, including races and training rides. By signing this Responsibility Agreement and Release, you acknowledge and agree that, in consideration of Velo Veneto’s provision of “the camp” services and accommodations to you:
1. Bicycling and bicycle racing pose inherent risks of illness, serious personal injury, or death, and property damage, to persons participating is such activities, and you are aware of and accept these risks while participating in any Velo Veneto activity.
2. While employees or agents of Velo Veneto may provide you with geographic directions during bicycle rides or races, they do not make, and each of them and Velo Veneto expressly disclaim, any representations or warranties with respect to the condition or safety of the roads on which you will ride or race. You are responsible for observing such road conditions and determining whether you are able to ride or race your bicycle safely in light of such conditions. In connection with the foregoing, please take notice that certain of the rides and races during “the camp” involve ascending and descending long, twisting mountain roads with hairpin turns and imperfect road surfaces. You are solely responsible for determining whether you are physically fit to attempt ascending such roads without endangering your health. You are also solely responsible for determining whether you have the requisite bicycling skills, and whether the bicycle you are operating is mechanically fit, for it to be safe for you to attempt descending such mountain roads. No employee or agent of Velo Veneto may be delegated, or is authorized to accept, any of the responsibility which you have in connection with making such determinations.
3. You are responsible for the maintenance and safe condition and operation of your bicycles and related equipment while attending the Velo Veneto camp.
4. You own both a helmet meeting Snell or ANSI standards, and protective glasses, and will wear such equipment while engaging in bicycling activities during your stay at the Velo Veneto camp.
5. You possess sufficient bicycling experience and bicycle handling skills to participate safely in the bicycling programs of the Velo Veneto camp.
6. Neither Velo Veneto or any of its employees or agents will provide you with any instructions on the safe operation of your bicycle in connection with any bicycle ride or race in which you may participate in during “the camp” and none of them is under any duty to provide you with such instruction.
7. You are responsible for providing your own insurance while attending the Velo Veneto camp, and for ensuring that such insurance covers your activities during “the camp” and is effective outside the United States of America, or your country of residence and citizenship. You are also aware and accept that medical services and facilities may not be readily accessible or of the standard to which you are accustomed.
8. Velo Veneto may make substitutions for services and accommodations where necessary or appropriate. Velo Veneto accepts no responsibility for weather, acts of war or terrorism, strikes, or other events beyond its reasonable control. You voluntarily accept these and other risks inherent in the nature of “the camp.”
9. Velo Veneto may ask you to leave “the camp” if your behavior is deemed by Velo Veneto to be offensive or dangerous to others. You agree that illegal drugs are not permitted at “the camp” and possession of them may result in immediate termination of your participation in “the camp.”
10. You release Velo Veneto and its employees and agents from all claims, demands, actions or causes of action for injuries, losses, liabilities or damages that you may have any time relating to or arising out of your attendance in “the camp”, your participation in “the camp” activities, and your travel to or from “the camp.”
11. I (the undersigned) have disclosed to Velo Veneto all relevant facts pertaining to my fitness and health.
12. I am over eighteen (18) years of age, and if married, have executed this document on behalf of myself, my spouse and the marital community.
13. This Responsibility Agreement and Release is governed by the laws of the State of California, USA.
In consideration of my being permitted to participate in the Velo Veneto camp, I agree to assume all risks of illness, injury, or death, and agree not to sue, and to release from liability and indemnify Velo Veneto, their owners, officers, agents, employees, and other persons or entities involved with the Velo Veneto camp, from all actions, claims, or demands for injury or damage regardless of the cause, resulting from my participation in the Velo Veneto camp. The contents of this document shall be binding upon me, my dependents, heirs, executors, administrators, legal representatives and assigns.
I have carefully read, in it’s entirety, the Velo Veneto racing camp “Responsibility Agreement and Release”. I have familiarized myself with all the information provided to me about the Velo Veneto racing camp. I understand its contents, and know of the truthfulness thereof. I am aware that this is a release of liability and a contract between myself ,3 Velo Veneto and Patrick Carroll. I agree to all stated conditions set forth in this Responsibility Agreement and Release, and I sign this agreement of my own free will.
Participant Signature_________________________________________________ Date:___________________________________
Note: If participant is under 18 years of age, Parent of Guardian must sign below.
Signature of Parent of Legal Guardian____________________________________________ Date:___________________________
Relationship to minor______________________________________________