Registration form for Cycling of Meso

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Registration is not complete until payment and waiver are received. Please return payment and registration/wavier form to Gori Julian & Associates, PC Attn: Cycling For Meso, 156 North Main Street, Edwardsville, IL 62025.
***Make checks payable to Gori Julian & Associates, PC*** I understand that participating in this event is potentially hazardous form me and that I should not enter and participate unless I am medically able. In consideration of the acceptance of this entry, I assume full and complete responsibility for any injury or accident which may occur while I am traveling to or from this event, during the event, or while I am on the premises of the event. I also am aware of and assume all risks associated with participating in this event, including but not limited to falls, contact with other participants, effect of weather an conditions of the premises. I , for myself and my heirs and executors, hereby waive, release and forever discharge Gori Julian & Associates, the event organizers, venue owner, sponsors, promoters, and each of their agents, representatives, successors and assigns, and all other persons associated with the event, for all liabilities, claims, actions, or damages that I may have against them arising out of or in any way connected with my participation in this event. I understand that this waiver includes any claims, whether caused by negligence, the action or inaction of any of the above parties, or otherwise. I authorize Gori Julian & Associates to use any photographs taken at this event for any and all future internal and external media publications.

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