NOTE: This is a SAMPLE Waiver/Release form. It is for guidance and informational purposes only. Final  wording should be as directed by the insured's counsel, but observing the principles represented within the  document. DO NOT RETURN IT WITH YOUR APPLICATION.  

WAIVER AND RELEASE OF LIABILITY -- READ BEFORE SIGNING  

In consideration of being allowed to participate in any way in the (name of organization) program, its related  events and activities, I, (name of participant) , the undersigned, acknowledge, appreciate, and agree that:  

1. The risk of injury from the activities involved in this program is significant, including the potential for  permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce  this risk, the risk of serious injury does exist; and,  

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF  ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for  my participation; and,  

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If,  however, I observe any unusual significant hazard during my presence or participation, I will remove myself  from participation and bring such to the attention of the Company immediately; and,  

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY  RELEASE, INDEMNIFY, AND HOLD HARMLESS (name of organization) and USA Cycling, Inc., their  officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers,  and, if applicable, owners and lessors of premises used for the activity ("Releasees"), WITH RESPECT TO  ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with  my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES  OR OTHERWISE, to the fullest extent permitted by law.  

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT,  FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL  RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY  INDUCEMENT.  

x _______________________________ Age: Date Signed:  

PARTICIPANT'S SIGNATURE  

FOR PARENT/LEGAL GUARDIAN OF PARTICIPANTS OF MINORITY AGE  

This is to certify that I, as parent/legal guardian with legal responsibility for this participant, do consent and  agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns,  and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities  incident to my minor child's involvement or participation in these programs as provided above, EVEN IF  ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.  

x _______________________________________________ Date Signed: __________  PARENT/LEGAL GUARDIAN SIGNATURE (print name)