Registration Form (English) If you are human, leave this field blank. Name * Category * Elite Individual - Men Elite Individual - Ladies Elite Duo - Mixed Elite Duo - Men Master Individual - Men Master Individual - Ladies Sport Individual - Men Sport Individual - Ladies Team/Club Name Name of Team Member (in Case of Duo) Passport Number and Issuing Country * Email * Mobile Phone * Gender * Male Female Age * Height * Weight * Emergency Contact (Name) * Emergency Contact (Phone Number) * Medical History (check all that apply and detail below): High blood pressure Diabetes Allergies (food, animals, etc) Respiratory problems (asthma) Cardiac problems Hip, knee, ankle, shoulder, arm or back injuries History of altitude illness Other Please Detail Any Checked Items Above (or any other pertinent medical information): Please Detail any Dietary Restriction or Special Requests: Blood Type Are you currently taking any prescription medication? Yes No Name of Medication Dosis of Medication Counterindications Do you have Personal Medical Insurance? Yes No Provider Name Provider Contact Info Policy Number Registration Policy: I understand that once registered in La Vuelta al Huascaran MTB epic that there are no refunds, nor extensions for the coming year or any other type of recuperation of the registration fee. This includes not being able to attend the event due to injury, scheduling conflicts or any other reason. I agree with the terms and conditions. * YES I hereby DECLARE UNDER OATH the following (please check each one): * I recognize that participation in the event “La Vuelta al Huascaran” is a physical activity that requires special knowledge, equipment and training, which has been communicated to me and explained properly by the organizers. I understand that the event involves risks associated with the weather including, heat, frost, extreme humidity as well as the physical conditions of the route. I also understand there are risks associated with the interaction between participants, organizers and/or the public. These risks have been explained to me and are acceptable to me. That in deciding to participate in the event, I declare that I have evaluated the risks and my own physical condition, training and knowledge in respect to the environment, location and route conditions; As such I declare that I am physically & mentally prepared and able to participate and fully and personally assume responsibility for this decision, excluding the organizers from any responsibility in this regard. That I have read, understand and agree to abide by the rules of the event and to abide by any decision made by the organizers and authorize them to assist me in all matters concerning mine and others safe participation in the event. That in the event of a medical emergency resulting from the event, the organizers will take care of my transfer to a suitable place for medical attention (clinic or hospital) and I understand that the responsibility of the organizers for me will conclude at this point. That by registering in “La Vuelta al Huascarán”, I release the organizers from any responsibility regarding what may happen to me during my participation in the event, or for any future consequences resulting from my decision to participate, even if these are derived from acts, actions, negligence or omissions of third parties other than myself while participating in the event. That I renounce my right to sue the organizers and/or any of their representatives, for present and/or future complications I may experience resulting from my participation in the event. That I authorize the medical service personnel provided by the event to perform any procedure, treatment or test that they deem necessary if I am in the condition to request it or not. I commit to terminate my participation in the event if I am asked to for medical or behavioral reasons. That I expressly waive any claim for payment or any remuneration for the use of my image in photographs, films, recordings, or any other promotional material that may include the use of my image which is made public by the organizers. I certify that I am of legal age or have permission from my parents, guardians or delegate. That I give my consent to all the above by signing this statement. I declare under oath to the veracity of the information provided. In the event that the above manifestation is found to not be true, the cyclist assumes the full legal consequences that may occur from his/her participation. Electronic Signature (please write your complete name) * Passport Number: * Submit
