News - Exercise
Superb Health 5k Registration Forms:
REGISTRATION FORM
“Superb Health 5K”
to benefit Special Olympics Vermont
Saturday, September 26, 2009 | State House Lawn Montpelier, VT | 9:00 a.m
Full Name: ___________________________________________________________ Age: ________ DOB: _________
Business/School Affiliation (if any):____________________________________________________________________
Mailing Address:___________________________________________________________________________________
City: ___________________________________________________________ State: _________ Zip: _____________
Phone: ___________________________ Email address: __________________________________________________
Circle one: I will be attending the event as a - WALKER RUNNER in a WHEEL CHAIR
Registration fee is $20 for adults. Children 12 and under are free. Donations are accepted.
Please make checks payable to: Special Olympics Vermont. Contributions are tax-deductible as allowed by law.
SPECIAL OLYMPICS VERMONT
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY, AND PARENTAL CONSENT AGREEMENT
In consideration of participating in the “Superb Health 5K”, I represent that I understand the nature of this event and that I and/or my minor child am qualified, in good health, and in proper physical condition to participate in such Activity. I acknowledge that if I and/or my minor child believe conditions are unsafe, I and/or my minor child will immediately discontinue participation in the Activity.
I fully understand that the “Superb Health 5K” event involves risks of serious bodily injury, including permanent disability, paralysis, or death, which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the “releases” named below; and that there may be other risks not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I and/or my minor child incur as a result of my and/or my minor child’s participation in the Activity.
I hereby release, discharge, and covenant not to sue Special Olympics Vermont, Special Olympics Inc, it’s respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the Activity takes place (each considered one of the “RELEASEES” herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the “releasees” or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk I, or anyone on my and/or my child’s behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the releasees from any loss, liability, damage, or cost which may incur as the result of such claim.
I have read this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK< AND INDEMNITY AGREEMENT, AND PARENTAL CONSENT AGREEMENT, understand that I have given up substantial rights by signing it freely and without inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue to be in full force and effect.
(PLEASE PRINT LEGIBLY):
Name of Participant: _______________________________________ Signature _______________________________________ Date: _________
Name of Parent/Guardian (if participant is under age 18): __________________________________ Signature ______________________________
