LEYDEN TOWNSHIP / MANNHEIM SCHOOL DISTRICT 83 MUNICIPIO DE LEYDEN / ESCUELAS DE MANNHEIM DISTRITO 83
TREK TO THE R.E.C. 5K Sunday, September 9, 2018 8:00 AM at Westdale School Domingo, 9 de septiembre, 2018 8:00 AM en la Escuela Westdale
Participant Name/Nombre del Participante: ____________________________________________________ DOB/Fecha de Nacimiento: ______________ Gender/Sexo: M ❒ F ❒ 2018-2019 School/Escuela:
MMS
MECC
W
R
S
E
Other: ___________
D83 Student Name to receive bag, shirt, etc. / __________________________________________ Nombre del estudiante que deber recibir la bolsa, camisa, etc.:
❒5K (Adult/Adulto): $10 ❒5K (18 and under): $5
❒1 Mile Walk (Adult/Adulto): $10 ❒1 Mile Walk (18 and under): $5
[Children under 10 must be accompanied by an adult participant / Los niños menores de 10 años deben estar acompañados por un participante adulto]
Adult T-Shirt/Camiseta de Adulto: S M L XL 2XL
Kids T-Shirt/Camiseta de Niño: S M L
Name of Parent/Nombre del Padre:________________________________________ [If Participant is under age 18/Si el participante es menor de 18 años]
Address/Dirección: _______________________________________________________________________________ E-mail/Correo electrónico: ___________________________ Phone/teléfono: _______________________________ WAIVER AND RELEASE OF LIABILITY I know that participating in a strenuous athletic event of this type is a hazardous activity. I certify that I (“Participant”), or the participant I am responsible for as parent or guardian and am permitting to participate in this event (“Minor Participant”), have no physical or medical condition that would interfere with participating in the Leyden Township 5K Road Race (the “Event”). Participant agrees to and shall abide by any decision of a race official concerning participation in or completion of this event. Participant assumes all risks to Participant and/or Minor Participant (if applicable) associated with participating in this Event including without limitation the risk of falls, contact with other participants, effects of weather, including high heat and/or humidity, conditions of the road course, and traffic on the course, and acknowledges that all such risks are known to and appreciated by the undersigned. Having read this waiver and knowing these facts, and in consideration of your accepting my entry, the undersigned, for myself (and for Minor Participant, if applicable) WAIVE, RELEASE AND DISCHARGE Leyden Township, Mannheim School District 83, their officers, agents and employees, the race directors, organizers, Event staff, volunteers and other participants, and any other persons or organizations involved in this event (the “Indemnitees”) from any and all liability, actions, claims or suits for personal injury, bodily injury or property damage of any kind that may accrue to me of Minor Participant arising out of the Event, and further agree to hold and save Indemnitees free and harmless from and against any and all claims, liabilities, losses, damages, costs and expenses of any kind arising from or in any way related to my participation in the Event and/or or the participation in the Event of Minor Participant (if applicable), even though that liability may arise out of the negligence or carelessness of persons named in this waiver. I further grant Leyden Township and Mannheim School District 83 full permission to use photographs, motion pictures or other records of the Event, including images of the Participant and/or Minor Participant (if applicable) for any legitimate purpose. Please be aware that these photos are for Leyden Township/District 83 use only and will be used in marketing materials.
Participant’s Signature/Firma del participante: ________________________________ Date/Fecha: ______________ Parent Signature (if applicable)/Firma del padre (si es aplicable):
For office use only:
Date:_________
By:______
Check #:_____
Cash:_______
________________________________ Date/Fecha:______________ Please make checks payable to / Por favor haga los cheques a: Leyden Township
Entered: Yes No
