Bike 2 Barberton Day Bike 2 Barberton Day – Poster Bike 2 Barberton Day Registration Register for Bike 2 Barberton Day, July 29th, 2017 Name* First Last Email* PhoneDate of Birth (MM/DD/YEAR)*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Number of Riders*Please enter a number from 1 to 10.Names & Ages of All Riders*I/We are Participating in:Bike Rodeo (K-5th Grade)1-mile Bike Ride10-mile Bike RideSelect all that apply.Waiver of Liability, Assumption of Risk, and Indemnity Agreement* I accept these terms In consideration of City of Barberton permitting me to participate in Bike 2 Barberton Day 2016, I hereby for myself, my child, my heirs, administration and assigns, waive and release any and all rights and claims for damages, which include but are not limited to serious bodily injury, including permanent disabilities, paralysis and death, may have against City of Barberton, its personnel and any other organizations connected with this event or activity, their successors, and assigns for any and all injuries which I may suffer while taking part in any activities with this event. I furthermore accept and assume all risk and responsibility for loses, cost, and damages I incur as a result of participating in the above mentioned activity. I acknowledge that my presence in performing these activities are strictly voluntary in spite of the unavoidable risk and/or dangers of such participation, and no one is forcing me to be present or to participate in the above mentioned activity. I have read this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, and fully understand that I have given up substantial rights by signing it and have signed it freely and without and inducement or assurance of any nature and intend it to be complete and unconditional release of liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid that balance, not withstanding, shall continue in full force and effect. Photography Release* I accept these terms I hereby authorize Barberton Community Foundation to publish photographs taken of me and my name and likeness, for use in printed and online materials. I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs. PARENTAL CONSENT FOR THOSE UNDER 18 YEARS OF AGE* I have minor children and have read the above statement I do not have minor children And I, the minor’s parent and/or legal guardian, understand the nature of the above referenced activities and minor’s experience and capabilities and believe to be qualified to participate in such activity. I hereby release, discharge, covenant not to sue the and AGREE TO INDEMNIFY AND SAVE HOLD HARMLESS and of the releases from all liability, claims, demands, losses, or damages on the minor’s account caused or alleged to have been caused in whole or in part by the negligence of the releases or otherwise, including negligent rescue operations, and further agree that if I, despite this release, I, the minor, or any one on the minor’s behalf make any claim against any of the above releases, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS each of the releases from any litigation, expenses, attorney fees, loss liability, damage, or cost any releasee may incur as the result of any such claim.