SRAM WC MTB XCO CHAMPS & SERIES Race#4
Diamant Estate, Suid Agter Paarl Road, Paarl
Saturday 18 May 2019

Please Complete and Submit the Form Below:

Email address *
Rider Surname: *
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Rider First Name: *
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Rider Date of Birth - yyyymmdd *
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Rider ID Number or (Passport Number, if not SA Citizen) *
Your answer
Rider Gender *
Rider Race Age: (How old will you be on 31 December 2019): *
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Race Category (Based on age at 31/12/2019) *
Cycling South Africa Licence/Membership Number (You may need to show your paid up licence at registration). Numeric answer only please:
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Your Nation Code (eg. RSA for South African Rider) *
Your answer
Note on Regions:
As a Western Cape Rider, your Region must match the address that you have registered on the Cycling South Africa website. This address should be where you live and not where you study or work. If you have moved or if you think your profile on the Cycling South Africa database is incorrect, please check it before entering this event. Getting this wrong can remove you from eligibility for Provincial Colours.
In which region of the Western Cape are you resident ? *
Mobile Phone Number: *
Your answer
Medical Aid Provider and Plan:
Your answer
Medical Aid Number
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Indemnity and Waiver to be Agreed to by Rider: *
I agree to participate in the event entirely at my own risk. I agree that I and my dependents do not have, and will not institute, any claims whatsoever against, and do hereby indemnify and hold harmless from all liability, Cycling SA, cycling commissions, organizers, other participants, sponsors, individuals, officials, marshals, assistants, helpers, agents, contractors, landowners, local authorities or employees of such persons and any person associated with the event in respect of any loss or damage whatsoever which I may suffer arising from any injury to my person or loss or damage to property as a result of, or arising out of, whether directly or indirectly, my participation in this event, including my arrival and departure there from and attendance at any ceremony or function thereof, however such loss or damage may arise and regardless of whether or not same were caused directly or indirectly by negligence albeit gross, of one or more of all of the aforementioned parties. I also accept that: The organizers shall accept no responsibility or liability for any injury, howsoever caused, to any person while on the premises or while utilizing the facilities thereon, as well as in respect of any loss or damage to property, howsoever caused or suffered by any person while on the premises or while utilizing the facilities thereon. I further accept the event rules above as well as all official rules of the specific sport discipline. (Where the rider is younger than 18 years of age, this must be completed by the Riders Legal Guardian).
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Email Address of Parent Guardian Where Applicable
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Phone Number of Emergency Contact Person: *
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Name of Emergency Contact Person *
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Team or Sponsor or School
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A copy of your responses will be emailed to the address you provided.
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