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:
Rider First Name:
Rider Date of Birth - yyyymmdd
Rider ID Number or (Passport Number, if not SA Citizen)
Rider Race Age: (How old will you be on 31 December 2019):
Race Category (Based on age at 31/12/2019)
NG (Nipper Girls, Race Age 8-10)
NB (Nipper Boys, Race Age 8-10)
SG (Sprog Girls, Race Age 11-12)
SB (Sprog Boys, Race Age 11-12)
JG (Sub Junior Girls, Race Age 13-14)
JB (Sub Junior Boys, Race Age 13-14)
YW (Youth Women, Race Age 15-16)
YM (Youth Men, Race Age 15-16)
JW (Junior Women, Race Age 17-18)
JM (Junior Men Race Age 17-18)
EW (Elite Women, Age 19+)
EM (Elite Men, Age 19+)
SW (Sub Veteran Women, Age 30-39)
SV (Sub Veteran Men, Age 30-39)
VW (Veteran Women, Age 40-49)
VM (Veteran Men, Age 40-49)
MW (Master Women, Age 50-59)
MM (Master Men, Age 50-59)
GM (Grand Master Women, Age 60+)
GM (Grand Master Men, Age 60+)
Cycling South Africa Licence/Membership Number (You may need to show your paid up licence at registration). Numeric answer only please:
Your Nation Code (eg. RSA for South African Rider)
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 ?
I am a Visiting Rider (I do not live in and am not registered as a Western Cape Cyclist)
City of Cape Town
Mobile Phone Number:
Medical Aid Provider and Plan:
Medical Aid Number
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).
Email Address of Parent Guardian Where Applicable
Phone Number of Emergency Contact Person:
Name of Emergency Contact Person
Team or Sponsor or School
A copy of your responses will be emailed to the address you provided.
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