Step 1 of 4 25% Contact InformationName* First Last Sex*MaleFemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Enter Email Confirm Email Subscribe To Our NewsletterSubscribe to our newsletter to receive updates about Cycle Waterloo races and events. We won't spam you with junk mail, promise. You can unsubscribe at anytime. Subscribe Emergency ContactEmergency Contact Name* First Last Emergency Contact Phone* Race InformationAffiliated Club / Team (Optional)Single Speed CategoryIf you want to qualify for the single speed awards we need to know that you're riding such a bike. Check this box if you're riding the event with a single speed bike. Fat Bike CategoryIf you want to qualify for the fat bike awards we need to know that you're riding such a bike. Check this box if you're riding the event with a fat bike. Race Distance*Select which race you'd like to take part in. If you choose the Steaming Nostril you will be required to select a starting wave below. The Runny Nose has only 1 starting wave, no selection is needed.Steaming Nostril – 65 kmRunny Nose – 40 kmStarting Wave*Limit 150 riders - You must have a UCI licence, OCA citizen permit or a USA Cycling domestic licence. *Additional invitations for the unfilled positions in wave 1 will be issued to riders of exceptional ability at the organizers discretion after the early bird registration cut-off date. Wave 1 - 11:10 AM (License Req.)Wave 2 - 11:15 AMUCI License Number (or equivalent)* Ride WaiverPlease read the waiver below and click 'I Agree' to continue registration.WAIVER, RELEASE & INDEMNITY I understand and agree that my participation in events, programs, races, or activities organized, operated, conducted and/or sanctioned by the Canadian Cycling Association and/or Provincial Associations and Various CCA Clubs and Members registered with CCA is conditional upon my execution of this document. I am aware that cycling, and in particular competitive cycling, endurance and BMX racing, involves the possibility of injury or death. I accept these risks, and all others arising from these events and programs, even if arising from the negligence, gross negligence or negligent rescue by those associated in any way with the Canadian Cycling Association events and programs I may be involved in, the venues at which these events and programs takes place or by those organizing, officiating, or participating in these events and programs throughout the year, including their respective officers, directors, employees, agents, servants, volunteers and representatives (the “Releasees”). I understand that all applicable rules for participation must be followed and that SOLE RESPONSIBILITY FOR MY PERSONAL SAFETY REMAINS WITH ME, including my physical and emotional preparation and fitness to participate in all events and programs throughout the year. I undertake and agree to remove myself from participation if I sense or observe any unusual hazard or unsafe condition, or if, at any time, at any event or program, I feel unable or unfit to safety continue for any reason. I give, a FULL RELEASE AND WAIVER OF LIABILITY AND ALL CLAIMS that I have, or may have in the future, against Canadian Cycling Association, and all other Releasees from all liability for any loss damage, injury or expense that I may suffer as a result of my participation in any part or parts of the events or programs or my presence at any venue at which they may take place, due to any cause whatsoever including the forms of negligence set forth in paragraph 2 above or from any breach of contract or statutory duty or other duty of care including any duty of care owed under the relevant Occupier’s Liability Act, on the part of the Releasees. I AGREE NOT TO SUE and I further agree TO INDEMNIFY AND SAVE HARMLESS the Releasees from all expenses, fees, liability or damage award or cost of any type whatsoever arising from my participation in these events or programs. I HAVE READ AND UNDERSTOOD THIS WAIVER, RELEASE AND INDEMNITY. I am aware that by signing this agreement I am waiving substantial legal rights (on my behalf and on behalf of my heirs, executors, administrators and next of kin), including the giving up of my right to sue. PARENTAL CONSENT FOR MINOR PARTICIPANT and INDEMNITY AGREEMENT I have read and understood the above waiver, release and indemnity, and have discussed the same with the minor person signing above. I am satisfied the said minor understands the waiver and release and his/her obligations as set out. In consideration of the participation of my minor child/ward I too agree to waive, release and indemnify the Releasees in the terms set out above. I am aware that by signing this agreement I am waiving substantial legal rights, which my minor child/ward and I, our respective heirs, executors, administrators and next of kin may have against the ReleaseesWaiver Confirmation* I Agree PHOTO / IMAGE RELEASE I hereby give Cycle Waterloo, its assigns, licensees and legal representatives the irrevocable right to use my name/photograph/image/audio recording/video recording/ and likeness (“My Image”) in all forms and manner including but not limited to publication on Internet Web Sites, broadcasts and any other publications as released to or by Cycle Waterloo. I understand that Cycle Waterloo cannot control unauthorized use of My Image by persons not associated with Cycle Waterloo once My Image has been published. I hereby forever waive any right to inspect or approve any publication of My Image by Cycle Waterloo. I have carefully reviewed and understand the above provisions and agree to be bound by them. I voluntarily and irrevocably give my consent and agree to this Release and Waiver.Photography Waiver Confirmation* I Agree PaymentClicking the 'Process' button below will take you to a PayPal gateway page where you will be able to make your payment.Single Rider Registration Fee*Single Registration - $90.00Cycle Waterloo Race Kit Available during early bird only! Coupon TotalHST and administration fees are already included in the registration price. No surprises, you pay what you see here. $ 0.00 CAD Once you hit process DO NOT navigate away from the page or hit refresh. PayPal may take a bit to load. Please be patient during this process. Refreshing will cause multiple entries and impact your race entry status. PhoneThis field is for validation purposes and should be left unchanged.