Chai Cyclist Registration

By registering here, you are committing a minimum of $180 sponsorship to Chai Lifeline. Your credit card will not be charged until Friday, May 28th to allow you as much time as possible to raise sponsorship money.
Please note that each individual registering to be a Chai Cyclist must complete the form below.

Each Chai Cyclist will be able to create their own personal web page to raise money. You can then send your sponsors directly to your personal page or www.chailifeline.org/bikethedrive/sponsor.php. The money they pledge on your behalf will then be deducted from your $180 commitment.
As a Chai Cyclist you qualify to earn one of the following great prizes. Raise $750 and you’ll receive an Apple iPod Shuffle, Raise $1,500 and you’ll receive an Apple iPod Nano, Raise $2,000 and you’ll receive an Apple iPod-Touch.

Once you have registered here, you are ready to go.  You do not need to register yourself through Chicago’s Bike The Drive webpage.

 To contact Chai Lifeline Midwest call: 847.763.1818 or click here to email us.

First Name:
Last Name:
Birth Date:
Gender:	Male Female
If under 18, person you are registering with:
Email:
COMMITMENT AMOUNT
Code: chaicyclist Commitment Amount: $
CONTACT INFORMATION
Street Address Line 1:
Street Address Line 2:
City:
State:
Zip:
Phone:
Emergency Contact Name:
Emergency Phone:
T-shirt Size:	Youth Medium (10-12) Small Medium Large X-Large XX -Large
LOGIN INFORMATION
Choose your username and password. You will need it to view your web page, and see who has sponsored you for this event. Username: Password: Re-Type Password:
CREDIT CARD INFORMATION
Name on Card:
Credit Card Number:
Expiration Date:
Waiver and Release By clicking below, I hereby acknowledge that bicycle riding, bicycle racing and bicycling events ("Bicycling") are strenuous activities beyond the capability of some people, and may cause minor, severe and/or permanent injuries or death to people who are not in sufficient physical fitness, training and/or experience. I have made my own determination as to whether I am able to safely participate in Bicycling. I recognize that the Chicagoland Bicycle Federation ("CBF") has not evaluated my ability to participate in Bicycling. I also recognize that advice dispensed through CBF may not be appropriate for me, and it is my responsibility to make this determination. I acknowledge that some Bicycling is a test of a person's physical and mental limits and carries with it, regardless of physical fitness or experience, the potential for death, serious injury and property loss. I assume the risks of participating in Bicycling. I certify that my level of fitness is appropriate to participate in Bicycling which I am voluntarily undertaking. I certify that I have sufficiently trained or prepared for the Bicycling I am undertaking and I have not been advised against participation in such activity by a health care professional. I, for myself, my past, present and future agents, attorneys, representatives, predecessors, successors, assigns, heirs and executors, do waive, release and discharge CBF, its past, present and future officers, directors, agents, employees, volunteers (including any individual giving a presentation, advice or information in conjunction with Bicycling), attorneys, any CBF members or event participants other than myself, parents, subsidiaries, predecessors, successors, affiliates, assigns, sponsors, and representatives (the "CBF Parties") from any and all manner of liability, claims for damages, causes of action, proceedings, compensation, attorneys' fees, costs and expenses of suits, claims and demands whatsoever, which may arise in the future from my participation in Bicycling through or involving CBF, including, but not limited to, any and all claims, losses or liabilities for death, injury, disability, property damage, medical bills, theft or damage of any kind, including economic losses, which may in the future arise out of or relate to my participation in or traveling to and from Bicycling through or involving CBF. I acknowledge that there may be mode of transportation, persons, dangerous or adverse road or path conditions, hazards, wildlife or hidden objects present during Bicycling through or involving CBF, and assume the risk related thereto of participating in Bicycling through or involving CBF. I assume all other risks associated with participating in Bicycling through or involving CBF, including contact or effects of other participants and effects of weather. I AGREE NOT TO SUE any of the CBF Parties for any and all claims made or liabilities assessed against them as discharged herein. I INDEMNIFY AND HOLD HARMLESS the CBF Parties from any and all claims made or liabilities assessed against them as a result of (i) my actions, inactions or negligence, (ii) the actions, inactions or negligence of the CBF Parties and others hereby indemnified, (iii) the conditions of the facilities, equipment or areas where the Bicycling is being conducted and (iv) any other harm, injury or damage caused by an occurrence related to or during Bicycling through or involving CBF. I GRANT PERMISSION for the use of my name and/or likeness relating to my participation in Bicycling of the CBF and I WAIVE all rights to any future compensation to which I may be entitled as a result of the use of my name or likeness. IF REGISTERING A MINOR, I represent that I am the custodial parent or legal guardian of the minor. I consent to the terms of the foregoing application form, including the waiver and release of claims, on his/her behalf. I affirm I have the authority to grant such consent. I AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER, I HAVE READ THIS DOCUMENT AND UNDERSTAND ITS CONTENTS. I understand and agree to the waiver and release