First Name:
Last Name:
Phone: (xxx-xxx-xxxx) *
Email: *

Emergency Contact Name:
Emergency Contact Phone:
Emergency Contact Relationship:

Location will you be starting from:

Location you plan to end:

Note: Sports drink will be provided at ride start locations.

I hereby declare, assert, and affirm that participation in Health and Wellness, Connecting Campuses ride is done having voluntarily and knowingly assumed all risks involved in this Special Program. The immediate physical risks and hazards associated with normal, vigorous physical activity include (but are not limited to) physical discomfort, fatigue, muscular soreness, falls, pulled or strained muscles, overuse injuries, heat stress, and the rare instance of abnormal responses of the cardio-respiratory system including heart arrhythmia, heart attack, stroke and sudden death.

In consideration of the acceptance of my entry, I, the undersigned participant, for myself, my family members, heirs, administrators, personal representatives, successors and assigns hereby fully release, discharge and hold harmless Grand Valley State University (GVSU), any sponsors, owners and operations of motor vehicles and officers, directors, employees, volunteers and lessors of any of the foregoing persons, or entities from all liability, whether resulting from negligence of any aspect of GVSU and hereby acknowledge that the above persons and entities have no obligation to provide medical care and have not undertaken the responsibility to do so. In the event that I receive medical care as a result of a medical emergency, I hereby consent to such care and fully release the person(s) providing such care from any and all liability, whether resulting from negligence or otherwise.

I authorize and consent to persons employed or contracted by GVSU whether by videotape, film, newsprint, written advertisement or otherwise, of any materials containing my name or picture and I release any sponsors and persons acting under authority from any claims I might have due to initial or subsequent publication of any such materials or photographs. I acknowledge that if my photo or name is used in such materials I will not be receiving any compensation whatsoever. I agree that the GVSU is not responsible for lost or stolen items. I represent that I have medical insurance. I hereby certify that I have fully read and understand foregoing release, waiver and covenant not to sue, and sign it voluntarily. I also agree to wear a helmet at all times during the ride.

I confirm that I am 18 years of age or older as of today's date.

Signature: Date: