A separate application/waiver must be completed on EACH participant

Accident Waiver and Release of Liability:   I, the undersigned participant, intending to be legally bound, hereby certify that I am physically fit and have not been otherwise informed by a physician. I acknowledge that I am aware of all the risks inherent in a canoe/trail bike/trail run event, including possible permanent disability or death, and agree to assume all of those risks. As a condition of my participation in the Jailbreak Triathlon, or any activities incident thereto, I hereby waive any and all rights to claims for loss or damages, including all claims for loss or damages caused by the negligence, active or passive, of the following: Columbia Cycling Club, Maury County Parks and Recreation, event sponsors, the canoe companies or any individuals volunteering or supervising such activities. In addition, I agree to abide by and be governed by the rules set forth. Finally, I specifically acknowledge that I am aware of all the risks inherent in canoeing, transporting the canoe, trail biking and running and agree to assume those risks.

Signature:  __________________________________________________       Date:  _______________

Parent/Guardian signature if under 18:  __________________________________________

First Name:  ___________________     Last Name:  ______________________      Male / Female (circle one)

Street/P.O.  ____________________________________________

City:  ________________________________     State:  ____________     Zip:  _________________

Phone:  ______________________   Email Address:  ______________________________________________

Age on September 26, 2009:  ___________     Emergency Contact:  ______________________________

Phone:  ___________________

My race partner will be:  _______________________________     from what city:  ________________________

If racing as a TEAM, both partners will participate in all three events, canoe-bike-run, and the times will be combined for awards. If racing as a RELAY both will canoe, one partner will bike, and the other will run when the bicyclist finishes.

We will race as a (circle one):   [Team Male/Male]    [*Team Male/Male 80+]    [Team Male/Female]    [Team Female/Female]

                                                        [Relay Male/Male]    [Relay Male/Female]     [Relay Female/Female]  

                                                        * New category for male teams whose combined age on race day is 80 years or more. 

Our category will be (circle one):   Male/Male     Male/Female     Female/Female

T-shirt size (circle):   Small     Medium     Large     X-Large     XX-Large

In an attempt to minimize the quantity of passing needed on the single-track bike course, we will seed the canoes in groups according to mountain biking ability. If you will be biking, please rate your current mountain biking ability:
______9.  Ranked as a Cat 1 (Expert) currently
______8.  Ranked as a Cat 2 (Sport) currently
______7.  Ranked as Sport or Expert in prior years but not competitive this season
______6.  Have raced mountain bike as a Cat 3 (Beginner) or off-road event and placed in the top half of my class
______5.  Have raced mountain bike as a Cat 3 (Beginner) or other off-road event placing in bottom half of my class
______4.  Minimal racing experience but I have over 100 miles of trail practice and generally keep up with competitive friends
______3.  Have ridden less than 100 trail miles but in competitive condition and do not have to dismount much
______2.  Have practiced trails some, but dismount at tough spots and steep hills
______1.  I am truly a beginner or very slow; put me in the slowest group

PRE-REGISTRATION ONLY; $55 EACH PERSON BY SEPTEMBER 12 (postmark date) if mailed; $50 for online registration via ACTIVE.COM.   After Sept. 12 registration is online only and price increases $5. [Total Team/Relay price is $100/$110].  Registrations are accepted in the order received.  New: Partners must register within five days of each other or the registration of the first will be returned (minus Active fee).  Entry fee is refundable (less Active fee) if canceled by Sept. 14, or, if we can replace your spot from a waiting list.  Please call Duane Leach at home to cancel 931.388.0135.  Entry fee includes a long sleeve T-Shirt, canoe rental and food for the entire family afterward. This race is limited to 272 participants or the available canoes. It fills up, so register early!

Make checks payable to Columbia Cycling Club for $55 for each participant ($110 per team/relay). Envelope must be postmarked September 12 or before.
Mail to: Columbia Cycling Club, 1116 W. 7th St. PMB 127, Columbia TN 38401