PAC Tour REGISTRATION FORM Complete and Mail to: PAC Tour, PO Box 303, Sharon, WI 53585 262-736-2453 or send back by email to notorangelo @pactour.com You can BOLD the TEXT to indicate your choice. Be sure to enclose/attach a photocopy or scanned copy of your medical insurance card, both sides please! Please fill in registration form and return (This is your Health Form) First Name Last Name Address City State Zip Home Phone Mobile Phone Email Occupation Sex Male Female Age Birth Date Birthplace Hair color Eye Color Height Weight MEDICAL- List two people to contact in case of an emergency Name Phone Relationship Name Phone Relationship Name of personal doctor Phone Name of Health Insurance Policy # List any physical disorders in case of an emergency: Allergies to Food, Medicine or other items Names of prescription medications currently taking Date of most recent Tetanus shot (we recommend you are current) Do you have any serious health problems cycling in the heat?
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PAC Tour REGISTRATION FORM
Complete and Mail to: PAC Tour, PO Box 303, Sharon, WI 53585 262-736-2453 or send back by email to notorangelo @pactour.com You can BOLD the TEXT to indicate your choice.
Be sure to enclose/attach a photocopy or scanned copy of your medical insurance card, both sides please!
Please fill in registration form and return (This is your Health Form)
First Name Last Name
Address City State Zip
Home Phone Mobile Phone
Email
Occupation Sex Male Female
Age Birth Date Birthplace Hair color
Eye Color Height Weight
MEDICAL- List two people to contact in case of an emergency
Name Phone Relationship
Name Phone Relationship
Name of personal doctor Phone
Name of Health Insurance Policy #
List any physical disorders in case of an emergency:
Allergies to Food, Medicine or other items
Names of prescription medications currently taking
Date of most recent Tetanus shot (we recommend you are current)
Do you have any serious health problems cycling in the heat?
Voler Jersey PLEASE “Bold” Selection or type YES in front of your choice
Men’s OR Women’s
Extra Small Small Medium Large Extra Large
Jersey Sleeve Style: Sleeveless Short Sleeve
Please indicate Jersey Cut by bolding or circling the word - RACE CUT (narrow) or CLUB CUT
T-Shirt Size: Men’s OR Women’s:
Extra Small Small Medium Large Extra Large
To register: Complete these forms and scan them to notorangelo @pactour.com or you can mail them with your deposit check. We would prefer you send a check to save Lon and Susan the processing fees.
Please email [email protected] to alert Susan that you are registering by mail. You will then need to print, sign and mail the Payment/Cancellation and Liability form to the office.
Make a copy for your records, noting the dates for payments.
To pay by credit card, use the MAKE A PAYMENT link on the PAC Tour web site under the Register Tab or by calling us with your credit card information. Susan’s cell: 612-804-9970
Payment Schedule/Cancellation Info : Include your non-refundable deposit amount with this form to hold your reservation. Final payment amount is based on the number of registered riders. Final payment dates are listed above for each tour.
Before you sign up we recommend you consider trip cancellation insurance to protect you in the event you are unable to attend or are forced to leave the tour early. Call Travel Guard at 1-877-901-7599 and mention PAC Tour. This insurance policy could be your refund if you need to cancel – provided you purchased the correct policy.
Riders requesting a roommate will be required to pay the single supplement amount (nonrefundable) 120 days before their tour to cover room costs should they cancel and a replacement rider does not register.
Final payments are due ~80 days before fly in of the tour or January 15th for all Desert Camp Weeks.
No refunds for Desert Camp or Peru cancellation after final payments have been made.
All other Tours Refund Policy: A 25% refund if cancellation occurs after final payments have been made.
No refunds if canceling within 29 days of tour start date.
A late fee of $100 will be assessed after 10 days – should a rider fail to make the final payment on time.
Tour prices are based on double occupancy hotels each night. You may pay an additional amount if a single room is desired or required. PAC Tour cannot guarantee finding everyone a roommate. Should you be the final person to register for a tour and wish double occupancy and a roommate is not available, you will be asked to pay the single supplement if you wish to register. If a roommate becomes available, you will be refunded the unused portion of the single supplement. During a tour if your roommate goes home, you will be paired with a new roommate. If you need to stay in a single room, you must pay the single supplement for the remainder of the tour.
Riders are responsible for extra costs due to tour changes caused by acts of God or other emergencies.
A PAC Tour gear bag is supplied and must be used to standardize truck loading. PAC Tour gear bags are not supplied for Desert Camp, WI, or Peru Tours.
I understand the cancellation, refund and policies of PAC Tour as stated above.
I acknowledge that this athletic event is an extreme test of a person’s physical and mental limits and carries with it the potential for death, serious injury and property loss.
The risks include but are not limited to, those caused by terrain, facilities, temperature, weather, conditions of athletes, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and or producers of the event, and lack of hydration. These risks are not only inherent to athletics, but are also present for volunteers.
I hereby assume all of the risks of participating and or volunteering in this event. I realize that liability may arise from negligence or carelessness on the part of the person or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault.
I certify that I am physically fit, have sufficiently trained for participation in the event and have not been advised otherwise by a qualified medical person.
I acknowledge that this Accident Waiver and Release of Liability (AWRL) form will be used by the event holders, sponsors and organizers, in which I may participate and that will govern my actions and responsibilities at said events.
In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:
(A) Waive, Release and Discharge from any and all liability for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to me or my traveling to and from this event, and the Following Entities or Persons;
PAC Tour, LLCLon HaldemanSusan Notorangelo
and their directors, officers, employees, volunteers, representatives and agents, the event holders, event sponsors, event directors, event volunteers;
(B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made by other individual or entries as a result of any of my actions during this event.
I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and or illness during this event.
I understand that at this event or related activities, I may be photographed. I agree to allow my photos, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and or assigns.
This AWRL shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I hereby certify that I have read this document; and, I understand it’s content.
Print Name __________________________
Signed ______________________________
Age_________ Date _________
If participant under the age of 18, please have guardian sign waiver.
