Southampton
Rotary Firecracker 8k, July 8, 2012
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Registration by Mail
Print and mail this form with your $20 check
before June 30, 2012 to:
Southampton
Rotary Club •
Click for Online Registration
First Name:
(print
clearly)_________________________________________________________________
Last
Name: (print
clearly)_________________________________________________________________
e-mail address:
_________________________________________________________________
Birth
Date __/__/____ ; Age on Race Day_____
Mailing
Address__________________________________________________________
Town_________________________
State_________ Zip_________
Area
Code & Phone Number ( ___ ) __________________
(Check
One) Male_____ Female____
Waiver: I know that running a road race is a potentially hazardous activity, and that I should not enter unless I am medically able and properly trained. I also know that although police protection will be provided, there may be traffic along the course route. I will assume the risk of running in traffic. I also assume any and all other risks associated with running this event including but not limited to falls, contact with other participants, the effects of weather, including high heat and/or humidity, an the condition of the road, all such risks being known an appreciated by me. Knowing these facts, and in consideration of your acceptance of my entree fee, I hereby for myself, my heirs, executors, administrators and anyone else who might claim on my behalf, covenant not to sue, and waive, release, and discharge any organization associated with the race, and the local governments and police, volunteers and sponsors from all claims for personal injuries or property damage, even if such injury of damage is caused by the negligence of any of these parties. I agree that the Firecracker 8K Run officials have the right to remove me from the race and related activities if they are of the opinion that is my best interest that I be removed, or if they are of the opinion that I have violated any USTF or IAAF rules. The undersigned further grants permission for this race and any organization conducting the race, and/or agents used by them, to use any photographs, videotapes, motion pictures, recordings, or any other record of this event for any purpose. I have read the forgoing and certify agreement by my signature below.
Signature______________________________________________________
Date__________________________