Splash and Dash Swim/Run Duathlon

July 13, 2005

NAME ____________________________________________________________

ADDRESS _________________________________________________________

CITY _____________________________________ STATE _____ ZIP _________

SEX ______ AGE ON RACE DAY ______  PHONE ________________________

E-MAIL ADDRESS __________________________________________________

AGE GROUPS:

19 and Under ___ 20-24 ___

25-29 ___ 30-34 ___

35-39 ___ 40-44 ___

45-49 ___ 50-54 ___

55-59 ___ 60+ ___

ACCIDENT WAIVER AND RELEASE OF LIABILITY

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 propert loss. The risks include, but are not limited to those caused by terrain, facilities, temperature, weather, condition 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 persons 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 an physically fit, have sufficiently trained for participation in the event and have not been advised otherwise by a qualified medical person.
I acknowlege that this Accident Wavier and Release of Liability (AWRL) form will be used by the event holders, sponsors and organizers, which I may participate and that it will govern my actions as 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 including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: Marlton Lakes Civic Association and Evesham Township, event sponsors, event directors, event volunteers representative, and agents; (B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all claims made as a result of participation in rhis event, whether caused by negligence of releases or otherwise.
I hereby consent to mrdical 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 photo, video or film likeness to be used for any legitimate purpose by the event holders, producers and or assigns.
This AWRL has been constructed broadly to provide a release and waiver to the maximun extent permissible under applicable law.
I hereby certify that I have read this document; and I understand it's content.
PARENT/GUARDIAN WAIVER FOR MINORS (Under 18 years old)
The undersigned parent and natural guardian or legal guardian does hereby represent that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnify each and all parties referred to above from all liability, loss, cost, claim for damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.

 

Signature _______________________________________________

(Parent or Guardian if under 19)

Date __________________________________

Make Checks payable to: DQ Tri/Du

MAIL TO:
Splash and Dash
P.O. Box 41
Barrington, NJ 08007

 

Home