慢性的な病気、あるいは現在発病中・再発中の病気があり、医師の手当を受けていますか? Please list any current or chronic medical conditions being followed by a doctor (Please be brief):
YES
NO
「YES」を選択の方は病名その他ご記入ください
(半角英語のみ)
現在薬を服用中ですか? Please list any medications you are taking
YES
NO
「YES」を選択の方は薬名その他ご記入ください
(半角英語のみ)
何か、薬にアレルギーはありますか? Please list any drug you are allergy to
YES
NO
「YES」を選択の方は詳細をご記入ください
(半角英語のみ)
虫刺されに対して過敏症ですか? Please list any hypersensitivity to insect or ocean animal stings
YES
NO
「YES」の場合詳細ご記入ください
(半角英語のみ)
他に健康上に関する内容はこちらへ記入してください。 Please list any other significant medical information(if applicable)
YES
NO
「YES」の場合詳細をご記入ください
(半角英語のみ)
レースに関して医療班に質問があればこちらへ記入してください。 Ask any questions you have for the medical personnel here: (Please be brief)
(半角英語のみ)
これまで健康上の要因でレースを控えることになったことがありますか? Have you ever dropped out during a race for medical reasons
YES
NO
「YES」を選択された方は詳細をご記入ください
(半角英語のみ)
スイム目標タイム SwimmerEstimated Time
時間
分
秒
【CYCLIST】
【CYCLIST】選手名 Name
(First Name) (Family Name) 例)YAMADA ZIRO
生年月日 Date of Birth
年
月
日
パスポート番号 Passport No.
(半角)
サイクルメンバーの国籍 Cyclist Nationality
例)JAPAN
サイクルメンバーの職業 Cyclist Profession
携帯電話番号(国) Mobile
例)090-1234-5678 JAPAN (半角)
性別 Gender
男性(M)
女性(F)
血液型 Blood Type
A
B
O
AB
Unknown(不明 )
Tシャツのサイズ T-shirt Size
S
M
L
XL
E-mail
(半角)
緊急連絡先(氏名) Emergency Contact Person
(姓) (名) 例)YAMADA TARO
緊急連絡先電話番号(国) Emergency Contact number
例)03-1234-5678 JAPAN (半角)
慢性的な病気、あるいは現在発病中・再発中の病気があり、医師の手当を受けていますか? Please list any current or chronic medical conditions being followed by a doctor (Please be brief):
YES
NO
「YES」を選択の方は病名その他ご記入ください
(半角英語のみ)
現在薬を服用中ですか? Please list any medications you are taking
YES
NO
「YES」を選択の方は薬名その他ご記入ください
(半角英語のみ)
何か、薬にアレルギーはありますか? Please list any drug you are allergy to
YES
NO
「YES」を選択の方は詳細をご記入ください
(半角英語のみ)
虫刺されに対して過敏症ですか? Please list any hypersensitivity to insect or ocean animal stings
YES
NO
「YES」の場合詳細ご記入ください
(半角英語のみ)
他に健康上に関する内容はこちらへ記入してください。 Please list any other significant medical information(if applicable)
YES
NO
「YES」の場合詳細をご記入ください
(半角英語のみ)
レースに関して医療班に質問があればこちらへ記入してください。 Ask any questions you have for the medical personnel here: (Please be brief)
(半角英語のみ)
これまで健康上の要因でレースを控えることになったことがありますか? Have you ever dropped out during a race for medical reasons
YES
NO
「YES」を選択された方は詳細をご記入ください
(半角英語のみ)
サイクル目標タイム CYCLIST Estimated Time
時間
分
秒
【RUNNER】
【RUNNER】選手名 Name
(First Name) (Family Name) 例)YAMADA SABUROU
生年月日 Date of Birth
年
月
日
パスポート番号 Passport No.
(半角)
ランメンバーの国籍 Runner Nationality
例)JAPAN
ランメンバーの職業 Runner Profession
携帯電話番号(国) Mobile
例)090-1234-5678 JAPAN (半角)
性別 Gender
男性(M)
女性(F)
血液型 Blood Type
A
B
O
AB
Unknown(不明 )
Tシャツのサイズ T-shirt Size
S
M
L
XL
E-mail
(半角)
緊急連絡先(氏名) Emergency Contact Person
(First Name) (Family Name) 例)YAMADA TARO
緊急連絡先電話番号(国) Emergency Contact number
例)03-1234-5678 JAPAN (半角)
慢性的な病気、あるいは現在発病中・再発中の病気があり、医師の手当を受けていますか? Please list any current or chronic medical conditions being followed by a doctor (Please be brief):
YES
NO
「YES」を選択の方は病名その他ご記入ください
(半角英語のみ)
現在薬を服用中ですか? Please list any medications you are taking
YES
NO
「YES」を選択の方は薬名その他ご記入ください
(半角英語のみ)
何か、薬にアレルギーはありますか? Please list any drug you are allergy to
YES
NO
「YES」の場合詳細ご記入ください
(半角英語のみ)
虫刺されに対して過敏症ですか? Please list any hypersensitivity to insect or ocean animal stings
YES
NO
「YES」の場合詳細をご記入ください
(半角英語のみ)
他に健康上に関する内容はこちらへ記入してください。 Please list any other significant medical information(if applicable)
YES
NO
「YES」の場合詳細をご記入ください
(半角英語のみ)
レースに関して医療班に質問があればこちらへ記入してください。 Ask any questions you have for the medical personnel here: (Please be brief)
(半角英語のみ)
これまで健康上の要因でレースを控えることになったことがありますか? Have you ever dropped out during a race for medical reasons
YES
NO
「YES」を選択された方は詳細をご記入ください
(半角英語のみ)
ラン目標タイム Runner Estimated Time
時間
分
秒
規約
大会公式の免責事項(英語原文)を掲載いたします。参加にあたりご承諾ください。
Disclaimer
・I understand that competing in the Event involves using public areas and roads used by other people and traffic and I am aware of the hazards involved. The hazards include but are not limited to: vehicle traffic, actions of competitors, spectators, Event personnel, weather conditions and my physical and mental state of health. In my judgment I have sufficient competence and experience to participate safely in the Event.
・I certify that I am physically fit, have sufficiently trained for participation in the Event and I have not been advised otherwise by a qualified medical person.
・I certify that I will be 18 years of age or older on April 29, 2017.
・I will follow the course set out for the Event, abide by the road and Event rules and follow the instructions given to me by Event officials, at all times. Failure to comply in any way with these matters may lead to me being removed from the Event and disqualified (at any time).
・I will wear the Event number and transponder as directed by the Event officials.
・Should the Event be cancelled or stopped for any reason, or personal circumstances arise that prevent me from participating in (or completing the Event), I accept that my entry fee is non-refundable.
・In consideration of the acceptance of my entry, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns as follows:
・I HEREBY WAIVE, RELEASE AND DISCHARGE from any and all liability for death, disability, personal injury, property damage, property theft and all other foreseeable risks, claims or actions of any kind (including negligence) whatever and however occurring which may arise, at any time, from or in connection with, directly or indirectly, my participation in the Event, the following persons or entities: The Event Organizers, Event officials and personnel, land managers and/or owners, event sponsors, volunteers, Taitung Government, Taitung Police, and all of their respective officers, directors, employees, independent contractors, representatives, agents and volunteers.
・I HEREBY INDEMNIFY AND HOLD HARMLESS the persons or entities mentioned above from any and all liabilities, claims or actions (including negligence) whatever and however caused which may arise, at any time, as a result of or in connection with, directly or indirectly, my participation in the Event and vis-à-vis any third party, as far as this third party suffered any damage or injury during the Event due to my participation in the Event.
・I acknowledge that the Event Organizers reserve the right to alter the advertised course or start time (at their absolute discretion).
・I consent to receive any medical treatment that may be deemed necessary in the event of injury, accident or illness during the Event, and I allow that information to be passed on to the Event Organizers or third parties (as deemed necessary by the Event Organizers)
・I authorize the use of my name, voice and picture and any information provided by me on this entry form to be used without payment in any broadcast, telecast, communication, promotion, or advertising, and I also agree that the information I have provided may be used by the Event Organizers for the purpose of promoting future or other events or for the promotion of the Event charity(ies), race sponsors products and services.
・I acknowledge that the Event Organizers have the absolute discretion in the award of any prizes, prize money or third party prize or award and I will abide fully and without dispute with all such decisions of the Event Organizers.
・I have read all the Event safety information, rules and conditions detailed in this form and on the entry form (and/or as detailed on the event website www.challenge-taiwan.com) and I agree to adhere to these rules and conditions at all times.
・I agree to the use of any photos taken by official photographers to be used for event marketing purposes and my email address can be used for communications from Challenge Family but is not to be released to any third parties.