Let Freedom Roll Entry Form
NAME: ________________________________________________________
AGE: ______ SEX: _____
ADDRESS: ___________________________________________________
CITY: ______________________________________ STATE: _______ ZIP:
_______________
EVENT: 5k In-Line* ____ 10K
In-line* ______ 5K Run ______
PHONE: ______________________________________
*Appropriate Safety Equipment Required
Waiver
As a participant in the event, I recognize and acknowledge that there
are certain risks of physical injury and I agree to assume the full risk
of any injuries, damages or loss which I may sustain as a result of participating
in any and all activities connected with or associated with such event.
I agree to waive and relinquish all claims I may have as a result of
participating in the event against the Township and its officers, agents,
servants and employees.
I do hereby release and discharge the Township and its officers, agents,
servants and employees from any claims from injuries, damages or loss which
I may have or which may accure to be arising out of, connected with, or
in any way associated with the activities of the event.
I futher agree to indemnify and hold harmless and defend the Township
and its officers, agents, servants and employees from any and all claims
resulting from injuries, damages and losses sustained by me arising out
of, connected with, or in any way associated with the activities of the
event.
I have read and fully understand the above Event Details, Waiver and
Release of all claims and permission to Secure Treatment.
SIGNATURE:____________________________________________________ DATE:
__________________
(Parent/Guardian,
if under 18)
HELMETS AND WRIST GUARDS / RACE GLOVES MANDATORY