Mass Bike Pike

The Mass BikePike Tour

Mail In Registration

You can fill out the form online and then print it or print it and fill it out by hand

First Name	Middle
Last Name

Gender Male Female Birth Date

Email
Enter Email Again

Day Phone Evening Phone

Cell Phone (if you plan to carry it with you while riding)

Address Line 1
Address Line 2
City, State Zip

I would like the vegetarian meal plan?
(Vegetarian meals will only be available to those who request them.)

Which route to you plan to ride? 30 50 65 Undecided

Do you plan to camp with us? Yes No-I plan to say elsewhere.

What size free T-shirt would you like? S M L XL

If you have a Coupon Code, enter it here

Were recruited by a former rider? Enter their name
Former rides who recruit new riders receive a credit against their registration.

Number of Jerseys ($55/each)? Size S M L XL

I acknowledge that I have read and agree to the terms of the event waiver

_________________________________
Signature

____________________
Date

Sign-Up
Regular rider registration is $375 + $55/jersey . Non-bicycling/drive and ride participants pay the same fees and receive the same services as regular riders.

Registration closes July 19th.
Cancellation Policy
All cancellations must be received in writing. Cancellations received by June 21st will be refunded minus $100/person. No refunds will be given after June 21st, but you can provide a substitute. Please notify us in writing.

Send Completed Form with a check for payment in full to

Mass BikePike Tour
52 Pleasant St. Suite A
Cambridge, MA 02139

Mass BikePike Tour
Event Waiver and Agreement to Participate

I ACKNOWLEDGE that the bike ride and camping trip I am going to participate in with The Mass BikePike Tours involves a dangerous activity, as does any bike ride or physical activity, including both known and unanticipated risks. I acknowledge that this ride carries with it the potential for death, serious physical and emotional injury, property damage, and property loss. I hereby assume all the risks of doing this ride voluntarily. I promise to ride in a safe and prudent manner, so as not to endanger myself or others. I agree to indemnify, reimburse and hold harmless Mass BikePike, its officers and employees for any injury caused by me, intentionally or unintentionally. I agree to wear a helmet at all times while riding.
In consideration of my application to participate in this ride, I hereby execute this Waiver and Release from Liability on behalf of myself, my personal representatives, my administrators, my heirs, my next of kin, my survivors, my successors, and my assigns, as follows:

A. I WAIVE, RELEASE, DISCLAIM and FOREVER DISCHARGE from any and all liability for me while riding in any rides sponsored by The Mass BikePike Tour, the following entities or persons: Bruce Lederer, and all other employees, volunteers, representatives, agents, assigns, funders and sponsors of The Mass BikePike Tour.

B. I INDEMNIFY AND HOLD HARMLESS the entities and persons specified in paragraph A above from any and all liability, loss, demand, claim or action at law or in equity that may hereafter be made or brought by those individuals or entities as a result of any of my actions during this ride. This indemnification and hold harmless agreement obligates me to defend any action brought against the entities and persons specified in paragraph A above as a result of any of my actions during this ride. Should I refuse to undertake my responsibilities under this paragraph, I will be liable for attorneys’ fees and costs incurred by the entities and persons specified in paragraph A above in defending any action brought against them as a result of any of my actions or those of my family members during this ride.

C. I CONSENT to receive medical treatment that may be deemed advisable as a result of any injuries I receive during this ride and agree that I am solely responsible for all costs, including diagnosis, treatment, medical transportation, and evacuation, that may become necessary for me or another person as a result of any of my actions during this ride. I am aware that medical services or facilities may not be readily available or accessible during some of the time in which I am participating in the ride or trip.
D. I AGREE that any photographs and audio or video recordings taken of me during my ride may be printed, reproduced and published in any manner anywhere without any further consent by me or my family members and without any compensation to me.

E. This agreement will be interpreted according to the laws of the Commonwealth of Massachusetts and exclusive jurisdiction for any legal claims arise out of it or in connection with the said event shall rest solely with the Commonwealth of Massachusetts, where The Mass BikePike Tour is based. If any portion of this agreement should be determined by a Court to be null and void, the remaining portions of the agreement shall remain in full force.
F. I CERTIFY that I have read this document, understand its contents in their entirety and have executed this document below without reservation or duress, on behalf of myself, spouse, children, heirs, estate and assigns.
___________________________ ________________________________ _________________
NAME (PRINTED Signature Date

ADDRESS_________________________________________________________________
PHONE __________________________ EMAIL __________________________________

[must be completed for participants under 18 years of age]
In consideration of ______________________________ (Minor) being permitted by Mass BikePike to participate in its activities, I further agree to indemnify and hold harmless Mass BikePike from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such or participation by Minor.

_____________________________ ___________________________ _____________________
Parent or Guardian (printed) Signature Date