*Name of your completed BRM more than 600km in past
Planned 2019 PBP Participation
Yes
No
*Insurance company which covers your ride during this event
*Type of insurance which covers your ride during this event
*Insurance number which covers your ride during this event
*Insurance validity covers this event schedule from start to goal.
Yes
*Liability insurance amount of money is more than JPY 100000000.
Yes
*Insurance covers you against death and disability
Yes
No
Name of roommate（Twin-bedded Room） ※Please fill out only participant of Clover Hokkaido 1200
（Rommmate needs entry Clover Hokkaido 1200）
Confirmation of entry fee ※The organizer will eventually do the room assignment. If different from your room request，we will return or collect the difference of participation fee at a later date.Can you agree?
Yes
規約
Waiver, release and indemnity to participate in events organized by Randonneurs Sapporo.
I acknowledge that I understand this waiver’s intent, and I, for myself, my heirs, executors, administrators, and representatives, do hereby agree with and will absolve and hold harmless the organizers of this Brevet Randonneurs Mondiaux (herein called Event) hosted by the accredited person by Audax Japan (AJ) of each and all items below:
1．I understand the risks inherent in Randonneur events, and approve, agree, and declare that I am physically and mentally capable of participating in and have the qualification to participate in the Event. I agree and guarantee to withdraw immediately from the Event in my judgment, when I find it unsafe to continue for any reason, including fatigue, injury and accidents during the Event.
2．I understand that the Event takes place on public roadway and accept the possible risks during the Event. I agree and guarantee to observe all local traffic regulations (in Japan), and to follow traffic lights and signs. Furthermore, I agree and guarantee to withdraw immediately from the Event in my judgment, when I find weather or road conditions are unsafe.
3．I fully understand the followings:
(a) The sport of cycling can be dangerous, exposing participants to many risks and hazards (herein called Risks) including permanent physical disorder, paralysis, or death.
(b) These Risks may result from my own actions, from actions of other participants of the Event, from conditions of the Event, or from accidents incurred by third parties.
(c) There are known and currently unforeseen Risks and possibilities of social and economic losses. I fully accept all the Risks and responsibility for loss, expense and damage caused by me incurred by participating in the Event.
4．I hereby release and forever discharge and hold harmless and agree not to sue the organizers accredited by AJ, volunteers, and the owner or the lender of the premises on which the Event takes place (herein called Released Parties) of any expense, compensation request, liability, loss or damage arising from my participation in the Event. Furthermore, I agree that, when, regardless of this waiver, release and indemnity, I or my representative submit a request for compensations to members of Released Parties, I shall compensate and protect each of Released Parties for all lawsuit cost, lawyer fees, requested compensations, damages and expenses incurred by said request.
5．I agree to receive medical treatment in case I suffer injury or disease during the Event. And I agree to pay the fee for the medical treatment I received.
6．I permit my name, voice, photographs, and images to be used, free of charge, in radio broadcasting, in television broadcasting, on the Internet website, in visual recording, in newscast, and other uses related to the Event.
7．I agree not to request a refund of the participation fee when the Event is cancelled under unforeseen circumstances, such as bad weather or disaster, not responsible for the organizers.
8．I agree that I present/submit my insurance information/document upon signing up to the Event to confirm that I am adequately covered by an insurance which meets the requirement of AJ. I also agree that I am responsible to secure adequate insurance coverage.
9．I agree that in case the schedule of the Event is altered due to unforeseen conditions, such as bad weather or disaster, it is my responsibility to reaffirm the validity of my insurance under the altered schedule. I agree that, if I find my insurance is not valid under the altered schedule, I will inform the organizer and refrain from starting. I also agree that I will not request a refund of the participation fee in said circumstances.
I hereby confirm that I have read this document and have fully comprehended its conditions, that I understand that by signing this form I have given up my rights as described in this document, that I have voluntarily signed without any coercion or guarantee, that I understand that this completely waives all responsibilities of Released Parties without any conditions within the laws, and that even in case any portion of this document be deemed void, remaining parts hold valid and effectual.
