This application for a World Inline Cup License has to be filled in, completed with the necessary documents, and submitted to the World Inline Cup Organization before athletes can register for the races. It cannot be accepted before the registration fee of EUR 50 has been paid to the World Inline Cup Organization. After sending the form there will be the opportunity to do an online payment by PayPal.

Athlete Registration/Application for WIC License

Personal Data

First Name:

Last Name:

Nationality (3-letter-code):

Country:

City:

ZIP:

Address1:

Address2:

Gender (male/female):

Mobile Phone:

E-Mail:

Date of Birth (YY/MM/DD):

Best Results

WIC Overall Ranking

2012:

2011:

2010:

WIC Best Results

1-2012 - City:

1-2012 - Place:

2-2012 - City:

2-2012 - Place:

Other Best Result 2012

1-City:

1-Place:

2-City:

2-Place:

World Titels 2012

Distance:

Place:

European Titels 2012

Distance:

Place:

National Titels 2012

Distance:

Place:

BANK INFORMATION - important

Bank Name:

Address:

ZIP / City:

Country:

BANK SWIFT / BIC code:

Route Number / IBAN no:

Account Name:

Account Number:

INSURANCE COMPANY INFORMATION

Personal Insurance No:

Insurance Company:

Address:

ZIP / City:

Country:

Website:

Phone Hotline:

Notes:

Agreement: I agree – hereafter and with sending the form – that I have an individual accident insurance and that I take part on my own risk at the events of the World Inline Cup. I agree that Iguana can communicate the information about my personal insurances to the local organizers or to the rescue services directly.

Waiver Responsibility: I acknowledge that inline skating is an activity involving a significant risk of personal injury, including disability and death. I agree that I take part on my own risk at the event and that I am solely responsible for my safety. I agree that I am solely responsible to be physically fit and sufficiently prepared to participate in this activity and to use equipment of a type and condition reasonably necessary to safely participate in this activity. With my registration I confirm that I have an individual accident insurance and that all medical expenses incurred will be my responsibility. I agree to waive and release any and all claims for injuries or damages, which I may incur during, as a result of my participation in any of the events, against the organizer. The organizer reserves the right to exclude a team or athlete from participating at the event if the athlete, the team or a team sponsor is in a lawsuit with the organizer. Further, I hereby grant full permission to use any photographs, motion pictures, recordings, or any other record of any of the events for any legitimate purpose, including commercial advertising.

WORLD INLINE CUP - Official Marathon Roller Series of FIRS

Athlete Registration/Application for WIC License

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