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All participants must sign the waiver and release of liability below:
In consideration of being allowed to participate in any way in the 2008 Crossroads Dash 15K Run/5K Run/5KWalk, the undersigned:
Agree that prior to participating, they will inspect the facilities and equipment to be used, and if they believe anything is unsafe, they will immediately advise race managers and refuse to participate.
Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including severe stress, permanent disability, or death and severe social and economic losses, which might result not only from their own actions, inactions or negligence, but the actions, inactions or negligence of others, the rules of play, vehicle traffic on the course, or the condition of the premises or any premises or any equipment used. Further, there may be other risks not known or reasonably forseeable at this time.
Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death.
Release, waive, discharge and covenant not to sue the Effingham Central Business Group, its affiliated organizations, their respective administrators, directors, agents, coaches and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as “releasees,” from any and all liability to each of the undersigned, his or her heirs and next of kin for any and all claims, demands, losses, or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the releasees or otherwise.
___________________________________ ___________
Signature of Applicant Date
___________________________________ ____________
Printed Name of Applicant Date
___________________________________ ___________
Signature of Parent or Legal Guardian Date
___________________________________ ____________
Printed Name of Parent or Legal Guardian Date
EVENT REGISTRATION:
Last Name: _____________________________________________
First Name: _____________________________________________
Address: _______________________________________________
City: ___________________________________________________
State/Zip: ______________________________________________
Phone #: _______________________________________________
E-mail_____________________________
Male:____ Female: ____
Date of Birth: _______________________
Age on June 14, 2008:________________
T-shirt Size: S M L XL (circle one)
Circle the race you are entering:
15K Run 5K Run 5K Walk
Fee enclosed: $______________________
Please read and sign the waiver and release of liability. Applicants who have not signed the waiver will not be allowed to participate.
Mail to:
Crossroads Dash
Effingham Central Business Group
P O Box 643
Effingham, IL 62401
Questions may be directed to Pat at 217/342-4147.
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