SAKSHAM CYCLOTHON APPLICATION FORM

For any details please log onto: sakshamcyclothon.com

Application Start date: 14th December 2017Application End Date: 15th January 2018 or as soon as

• An applicant can submit up to 10 forms• Application must be submitted along with a

photocopy of your ID proof (Aadhar Card, Driver’s licences, Passport), the form will be rejected otherwise

CRITERIA: Amateur Race:

• All participants must be 15 yrs of age or above.

Green Ride: • All participants must be 12 yrs of age or above.

• All participants are compulsorily timed using the RFID technology

SAKSHAM CYCLOTHON

APPLICATION FORM


APPLICATION FORM FOR RACE CATEGORY: AMATEUR & GREEN RIDE

APPLICATION FEES:• INR 500Amateur Men & Women: • FREEGreen Ride:

HOW TO APPLY:• Application Forms can be downloaded from the website

• Application forms can be submitted at the Indore Cycling Association


*

PERSONAL INFORMATION *First name:_______________________________________________ Middle name:______________________________________________*Last name:________________________________________________ *Mobile Number:__________________________________________ *Email: ___________________________________________________*Gender: Male / Female* *Address: _________________________________________________*Nationality:__________________________ *Blood Group:______* S 36 M 38 L 40 XL 42 XXL 44

*Emergency Contact Name: ________________________________*Emergency Contact Number:_______________________________ *ID proof:Note: No bibs will be given at the Rider Pack Collection without the

*History of Illness Yes No

*

Note: T-shirt size is not standardized and depends on fabric and supplier

APPLICATION FORM

recent photograph *passport

Size

BHUBANESWAR | INDORE | MUMBAI


• Payment can be made while submitting the forms atthe Indore Cycling Association.

*PAYMENT INFORMATION

REFUND POLICY:

cancel any application basis a technical review. Any amount collected from these applications alone will be refunded in full (excluding bank charges wherever applicable)

I acknowledge that the cycling event to be conducted on 21st of January 2018 is an extreme test of a

person’s physical and mental limits and carries with it the potential risk for death, serious injury and

property loss. There are both known and unanticipated risks. The known risks include, but are not

limited to travails by road, temperature, weather, the physical and mental condition of the participants

including my own physical and mental condition, my acts or omissions or failur

emergency treatment or other services rendered, consumption of food or drink, lack of hydration,

latent or apparent defects or conditions in any equipment or property supplied by the Promoters, or

nal

events. I understand and acknowledge that the above listing is not complete or exhaustive, and that

eseeable or

unforeseeable, may also result in injury, or damage to myself or property, and I expressly accept and

I expressly agree, covenant, and promise to accept and assume all responsibility and risk for injury,

death, illness or disease, damage to myself or to property, to participants, spectators or to other third

parties and their property, arising from or relating to my participation in the Promoters - sponsored

practices, activities and/or events and all related activities. I am voluntarily electing to participate in,

attend, Promoters - sponsored activities and/or events in spite of these risks. I certify that I am physically

evocably waive, release and

forever discharge from any and every claim, demand, action or right of action of whatever nature or

kind and all liability of any kind which may hereafter accrue to me in connection with my participating

in Saksham Cyclothon - sponsored practices, activities and/or events, Promoters - their past, present

the “Releases”) I HEREBY WAIVE, RELEASE, DISCHARGE, HOLD HARMLESS AND PROMISE TO

INDEMNIFY AND NOT TO SUE the Releases and the sponsors of Promoters - sponsored practices,

activities and/or events, the Promoters and, and employees through or by which practices and/or events

will be held, (the foregoing are also collectively deemed to be Releases) FROM ANY AND ALL RIGHTS

AND CLAIMS INCLUDING CLAIMS ARISING FROM THE RELEASEE’S OWN NEGLIGENCE.

Riders consent to the use of all photographic or video material pertaining to their participation in the

said event made by the organizers.

Applicant’s Signature:

*WAIVER FORM(*MUST BE SIGNED FOR ENTRY ACCEPTANCE)


SAKSHAM CYCLOTHON APPLICATION FORM

Documents

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