CertificationofEligibility,AcknowledgementofRules, WaiverofLiability&PermissionRelease

http://go.asme.org/HPVC

HumanPoweredVehicleChallenge2013

(HPVCFORMS2,3,5)

HPVCLatinAmericaEventUniversidadSimonBolivar,Caracas,VenezuelaFebruary2224
(RegistrationdeadlineDecember28,2012)

HPVCWestEventSanJoseStateUniversityatNASAAmes ResearchCenter,MoffettField, CaliforniaApril1214,2013(RegistrationdeadlineFebruary15) HPVCEastEventFerrisStateUniversity,BigRapids,MichiganApril2628,2013 (RegistrationdeadlineMarch1)

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***Thisisarequireddocumentforallteammemberstoreviewpriortoorduringregistration*** Youwillbepromptedtoagreetothetermswhenregisteringandmaybeaskedtosignthisformpreceding theevent.Ifyouareunabletocertifyanypartofthisdocument,checkwithyourteamcaptaintoreviewthe itemsinquestion.Pleaseobserveyourdeadlines. Anyrequestsforexemptionfromspecificsafetyrequirementsmustbesubmittedinwritingwithin10days followingyourvehicle/teamregistrationtoHPVCChiefJudge,ChristopherWlezien (chriswlezien@gmail.com),usingHPVCFORM4RequestedExemptionstotheSafetyCertification.

YouCertifyandAcknowledgeallofthefollowing

1) Thedesignandconstructionofthevehiclehasbeencarriedoutwithdueconsiderationofoccupantand bystandersafety; 2) Thedesignofthevehiclehasincorporated: a) abrakingsystemthatcanbringthevehicletoastopfromaspeedofapproximately15milesperhour inadistanceof20feetorless, b) asteeringsystemthatwillallowthevehicletoturnwithina25footradius, c) rolloverprotectionforridersandstokers,unlesswaivedbythechiefjudge,and d) safetybelts,and,wherefeasible,shoulderharnesses,unlesswaivedbythechiefjudge; 3) Thevehiclewillhavesuccessfullycompletedtestsofitems2aand2babovebeforeitsarrivalforthe competition; 4) Thevehiclehasbeeninspectedtoassurethatallsurfacesarefreefromsharpedgesandprotrusionsor thatsuchedgesandprotrusionshavebeenadequatelycoveredwithpaddingmaterial; 5) AllridersandstokersassociatedwiththisvehiclewillwearhelmetsthatmeetANSIStandardZ90.4while operatingtheaboveHumanPoweredVehicleoranyotherhumanpoweredvehicleeitheronorinclose proximitytoanyeventcourse; 6) Allridersandstokerswillwearbelts(andharnesses,asappropriate)atalltimeswhenthevehicleisin motion;and 7) Allridersandstokerswillhavehadnotlessthan30minutesofridingexperienceintheirvehiclepriorto thecompetition.

8) AllofyourteammembershavereadtheHPVCrules.(Requestsforadditionalclarification,ifany,should besubmittedseparately.) 9) Youagreethatyourvehicleissubjecttoonsiteinspectionandtestingandthatanymodificationtothe vehiclethatreducesthesafetyofthedesigntoanunacceptablelevelintheviewoftheCompetition Officialsmayresultinthedisqualificationofthevehiclefromthecompetitionorevent. 10) WaiverofLiability:IherebyreleaseASMEfromliabilityforanyandalldamagesandlosses,including, withoutlimitation,thoserelatingtopropertydamage,lossofincome,injury,painandsuffering, incapacity,dismemberment,ordeathtomeinconnectionwithorresultingfrommyparticipationin theseactivities.

WAIVEROFLIABILITY

RidingaHumanPoweredVehicleisadangerousactivity.Injuryordeathcouldresultfromparticipationin HumanPoweredVehicleChallenge.Participationinthisactivityisatyourownrisk.

ASME,itssections,chapters,officers,directors,employeesandvolunteerstakenoresponsibilityforthe safetyofanyparticipantinthisactivity.

Iunderstandtheriskinvolvedinridingthehumanpoweredvehicleandagreetowaiveallliabilitytowardthe ASME,itssections,chapters,officers,directors,employeesandvolunteersregardlessofanyperceivedor provennegligence.

PERMISSIONRELEASE

IherebygrantpermissiontoASMEandanyoftheirsuccessorsorassigns,fortheuseofanyphotographs, filmsorrecordingsthattheyhaveheretoforetakenofme,myteamandmyvehicle.ASMEmayuse,publish, publicize,promote,advertise,ortelevisemyname,portraitorpicture,andvoice.IherebyreleaseASME fromanyclaimsanddemandsarisingoutoforinconnectionwithanyuseofsaidphotographs,filmsor recordings,includingallclaimsforlibel.IacknowledgethatASMEisthesoleownerofallrightsinandtosaid photographs,filmsandrecordingsforallpurposes.