Series Registration Form

Series Registration Form for TeamsCYBATHLON Wheelchair Series 2019
The CYBATHLON Wheelchair Series Japan 2019 is organised by the CYBATHLON Wheelchair Series Japan 2019
Organising Committee in cooperation with CYBATHLON / ETH Zurich (hereafter the CYBATHLON Seriesorganisers).
This form serves as the registration form for participation in the CYBATHLON Wheelchair Series Japan 2019that will take place in Kawasaki in the Greater Tokyo area of Japan, from May 4 until May 6, 2019.
The registration will only become valid and binding after acceptance of the registration form by the
CYBATHLON Series organisers.
Only teams can register for participation in the CYBATHLON Wheelchair Series Japan 2019. A team consists of atechnology provider (at least one person from a research laboratory or company, or a private individual) and at
least one pilot (person with a physical disability).
The following roles define a team:Team officials:
Team manager

Responsible for the team participation in a specific discipline.

Pilot

Person with disability participating in a discipline.

Backup pilot if
applicable

A backup pilot takes the role of the pilot if the pilot drops out or withdraws theparticipation.

Care person

A care person (also caregiver or carer) is a member of the pilot’s social network
helping with activities of daily living.

Support person(s)Supports the team, e.g. technical support, communication, etc.

The main responsible person for the team is the person who shall be authorized to represent a team, to sign
documents on behalf of all team members, to take responsibility for the team. If the main responsible person is
also present at the CYBATHLON Wheelchair Series Japan 2019 as a team official, she/he needs to be aregistered, e.g. as a team manager, pilot or support person. However, it is not mandatory for the main
responsible person to be present at the CYBATHLON Wheelchair Series Japan 2019.

A team will receive 1 starting slot-

Safety review process of device (TecCheck) and pilot (MedCheck)
CYBATHLON Series organisers' hotel shuttle service for pilot, backup pilot and team manager (if travellingwith the pilot)
Medical and infrastructural support (incl. team locker room)CYBATHLON Wheelchair Series promotional activities to introduce the team (online/print) and connection
with media
Team accreditation (access to team zone and team stands)
Meals on the competition day and on the mandatory registration, TecCheck and MedCheck day for theteam manager, pilots and care persons

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Additional support person fee
Additional support persons may be registered for a fee of JPY 15,000.-. The fee will cover the below.
- Additional support person accreditation (access to team zone and team stands)- Meals on the competition days and on the mandatory registration, TecCheck and MedCheck day
To register the additional support person for participation as team member in the CYBATHLON Wheelchair
Series Japan 2019, payment of the abovementioned fee is required. The registration fee needs to be paid within
30 days after acceptance of the support person registration form (separate form) by the CYBATHLON Seriesorganisers; otherwise, the additional support person may not have access to the team area. In case the payment
is made after March 30, 2019, proof of remittance must be provided to the CYBATHLON Series organisers.

Travel funding
Teams affiliated with universities, early-stage start-ups and non-profit organisations are invited to apply for partial
travel funding for CYBATHLON Wheelchair Series Japan 2019. Travel funding will be distributed on a competitive basis.
Selection will rely on the quality and maturity of the technology of the device, the potential risks with respect tofunction and safety, the experience of the technology provider, the geographical origin and the financial possibilitiesof the teams. Please provide the respective information below (1.1).
1.1

Application for travel funding

□ yes
□ no

Registration Priorities
The total number of pilots eligible to start is limited to twelve:-

Applicants will be registered on a first-come, first-served basis, subject to acceptance by the CYBATHLON
Series organisers.

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Important Dates
A.

Opening of team and pilot registration

February 11, 2019

B.

Opening of support person registration

February 11, 2019

C.

Deadline for submission of completed and acceptable device safety
documentation (TecCheck)

March 15, 2019D.

Deadline for submission of pilot registration incl. required documents

March 30, 2019

E.

Deadline for support person registration

March 30, 2019

F.

Mandatory onsite registration, onsite technical check of devices (TecCheck), andonsite medical check of pilot (MedCheck) at the CYBATHLON Wheelchair Series
venue

G.

CYBATHLON Wheelchair Series Japan 2019

May 4, 2019

May 5-6, 2019

Race and Task Rules
Please study the race and task description of CYBATHLON Wheelchair Series 2019 carefully prior to registration(https://www.ethz.ch/content/dam/ethz/special-interest/conference-websites-dam/cybathlondam/documents/Team_Registration_03_18/CYBATHLON_Races_and_Rules.pdf).

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Device/Project Information
Please provide a detailed description of your device or the device that you plan to develop for CYBATHLON
Wheelchair Series 2019 if the device is not yet finalized. Please provide as much information as possible andattach drawings, photographs, videos, and other material (publications, patents, risk management files). This
information is required to assess the functional status and safety of the device and will be used as one of thecriteria for acceptance of this registration. All information will be treated as confidential (see privacy section
below).
3.1

Name of the device or project

3.2

Description of the device(general function, goal of use)

3.3

Components (materials, joints,
actuators, sensors, controllers)

3.4

Attachment to pilot

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3.5

Function and movement

3.6

Potential risks

Privacy
Japanese privacy law is applicable. The CYBATHLON Series organisers warrant that the processing of personal
data will be carried out lawfully, in good faith, and in an appropriate fashion. Personal data will be protectedagainst unauthorized processing.
Upon request, e-­‐mail address(es) may be disclosed, mainly to sponsors (e.g. collaborations, partnership,
marketing) or the public for non-­‐commercial purposes regarding the CYBATHLON. Other personal data will not be
disclosed without consent.
For all teams, in any case, the following information will be published to introduce the teams to the public (e.g.
for the CYBATHLON Wheelchair Series Japan 2019 website, the event leaflet, and team introduction during thecompetition by the moderator):•

Team name•Team origin (City, Country)•

Team affiliation (Company, Institution)•

Team officials’ names such as pilot(s), team manager, support person(s), main responsible person

Therefore, with the above-mentioned exceptions, all information provided by the applicants will be treated asconfidential unless the respective person consents that it may be disclosed (please tick respective boxes in therespective sections).

Team Information
4

Team

4.1

Team name(max. 14 characters incl. spaces)

4.2

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5

Organisation information

5.1

Name of organisation, unit,
laboratory

5.2

Location (country, state, city)

5.3Type of organisation□ university/non-profit□ company□ other:

6

Main responsible person

6.1

FAMILY (LAST) NAME

6.2

First name, middle name

6.3

Institution/Company

6.4

Street, Number

6.5

Postal code

6.6

City

6.7

Country

6.8

Citizenship6.9

Email address

6.10

Phone office

6.11

Phone mobile

6.12

Title

____________

□ Ms
□ Mr
□ other:

6.13

Email address may be disclosed forevent related media purposes,
sponsors, or public

7Team manager

7.1

Same as main responsible person____________□ yes, I allow disclosure□ no, I do not allow disclosure□ yes□ no (please complete below)

7.2

FAMILY NAME

7.3

First name, middle name

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7.4

Phone mobile

7.5

Email address

7.6

Title

□ Ms
□ Mr
□ other: ____________________________________________

7.7

Email address may be disclosed forevent related media purposes,
sponsors, or public□ yes, I allow disclosure□ no, I do not allow disclosure

Conditions of Participation
After the CYBATHLON Series organisers have reviewed and decided the acceptance of this registration form, theapplicant will be informed about the next steps. The applicant will be asked to submit further documents andforms to assure safety of the device and insurance of the technology provider and pilot. The documentation
listed below shall be sent to teams@cybathlon.com before the deadline D. (see Important Dates). If proper
safety cannot be guaranteed, as assessed by the CYBATHLON Series organisers at their sole discretion, the team
may not participate in the CYBATHLON Wheelchair Series Japan 2019.
Required Pre-event•••

Device safety documentation (TecCheck) according to protocol including:oCompleted CYBATHLON TecCheck protocol (provided by CYBATHLON Series organisers)o

CE, FDA or equal certification (copy of certifications) or detailed risk analysis, in English. If a new
development/prototype is used or if certified components are combined or modified, a risk
analysis of the overall system is required (template is provided by CYBATHLON Seriesorganisers). If certified devices (CE, FDA or equivalent) are used as intended (as declared in thecertification), a statement that the device has not been modified and that the device will only
be used as intended together with the device manual and certification is required.

oPhotos of the device including overviews and close---up views.

oVideo proving functionality of the device including different views of the device showing function
with and without pilot using the device.

Pilot registration including:o

Pilot registration formoWritten confirmation signed by a medical doctor that the pilot is fit for participation in CYBATHLON
races in English. A document written and signed by a medical doctor is required.

Passport type photo of each team official (for accreditation/badge, portrait, w: 480 px, h: 640 px): Pleasename the photo with first name, FAMILY name, and function in the team and with the team name (e.g.
John_SMITH_TeamManager_BestTeamInTheWorld.jpg)

Once onsite, at the registration, each team official will be asked to sign the following documents:
Required Onsite•

Adequate proof of insurance for all team officials, namely against accidents, injuries, and personal
liability. In any case, insurance is the team officials’ own responsibility. Every team official will be asked,
onsite, to sign a registration sheet, including insurance statements. If that document is signed, the
CYBATHLON Series organisers must and will assume that adequate insurance coverage has beenobtained as requested.

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Confirmation of usage of photographs and recordings. Team officials may be photographed and filmed
during the CYBATHLON Wheelchair Series Japan 2019. Photographs and films may be used to further
promote the CYBATHLON. The undersigned team officials will be asked, onsite, to sign a registration
sheet to confirm that photographs, live broadcast, and recordings can be used without financial
compensation and without geographical or time restrictions.

The technology provider bears full liability in case of an accident due to a defect of the device.
CYBATHLON recommends pilot and technology provider to make a mutual agreement outlining liability
in case of an accident. Importantly, the teams shall provide the pilots with sufficient training of the tasks
prior to the competition.
In any circumstances, at any point before or during the CYBATHLON Wheelchair Series Japan 2019, the
CYBATHLON Series organisers reserve the exclusive right to reject or exclude teams or their officials, e.g. if safety
conditions are not fulfilled, submitted forms are incomplete or required information is not provided. At any
point during the CYBATHLON Wheelchair Series Japan 2019, the devices may be inspected by the safetycommittee of CYBATHLON. If the committee considers that the safety requirements are not met or if the teamrefuses the inspection, the team will not be allowed to participate in the competition. Safety documentation andall other information is treated as strictly confidential.

Disclaimer
The CYBATHLON Series organisation refuses any responsibility for hazards caused by the devices used or that
occur during participation in the CYBATHLON Wheelchair Series 2019.

Agreement
The undersigned confirms that the application form is filled out correctly and truthfully.
The undersigned and the team have understood that the organisers may reject or exclude the team or single
pilot, if device criteria (with respect to function and safety) or pilot criteria are not met in the judgement of theorganisers.
The undersigned and the team have read, understood and accepted the Races & Rules for CYBATHLON
Wheelchair Series 2019 and accept any modification that will be made in the rules.
The undersigned and the team agree to participate in Radio/TV productions, cooperate with any media partnersof the CYBATHLON, and accept that, footage, and photo material of the CYBATHLON Wheelchair Series Japan
2019 including the competition will be published.
Although all possible precautions shall be taken to protect pilots by the technology provider and as much as
possible by the CYBATHLON Series organisers, participating pilots acknowledge that the technology used in thisevent may not have been fully tested by the technology provider (research lab or company) and it is not possible
to eliminate all risks and unforeseen hazards. Pilots taking part in this event require medical clearance and doparticipate at their own risk. Technology providers such as research labs or companies do participate at theirown risk.
Participating teams acknowledge that adequate insurance of all the team officials, especially against accidents
and injuries, is required to participate.
Please note that completing the registration form does not automatically guarantee the team participation at
CYBATHLON Wheelchair Series Japan 2019. The team’s registration will be reviewed by the CYBATHLON Seriesorganisers and the registrant will be informed about the preliminary acceptance to participate in the
CYBATHLON Wheelchair Series Japan 2019.
Applicants will be notified of any changes to the Races & Rules for CYBATHLON Wheelchair Series 2019
mentioned in this form.
Recourse to the courts concerning decisions of the CYBATHLON Series organisers is not permitted.
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Now and therefore
I, the undersigned main responsible person, representing the team in the CYBATHLON 2019 and its preparation
stage acknowledge herewith that participation/participation of:(please write your research lab/company name here)
in the event involves the risks inherent in such events with prototypes. I assume all the risks of CYBATHLON
Wheelchair Series Japan 2019 and its preparation stage, including health and personal safety risks involvng myteam (i.e. caused by or incurred by my team). Furthermore, I am obligated to follow instructions delivered by
the CYBATHLON Series organisers at all times.
For the avoidance of doubt, participation in the CYBATHLON Wheelchair Series Japan 2019 is governed by
Japanese law.
Therefore, in consideration of the risks, I, the undersigned, intending to be legally bound, consent to theassumption of such risks. I confirm that the content of this form is true and complete
Please send both an electronic AND a printed, signed (wet ink) and scanned copy by email to the CYBATHLON
Series organisers (teams@cybathlon.com).


Date


Place


Name and signature of main
responsible person

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