Jersey Genesis Triathlon & Bambino Biathlon
Race Application
First Name __________________________ Last Name ___________________________
Address __________________________________________________
City _______________________________ State _______ Zip
_________ Phone ____________
Sex ______ Age ______
Entering as: (circle one) individual Fireman Division
Policeman Division Veteran Division Port
Resident FirstTimer
Please read carefully before signing: In consideration
of the acceptance of my entry in the Jersey Genesis Triathlon, I, my heirs,
executors and administrators hereby discharge the Port Republic Athletic
Fund, The Port Republic Fire Company, the cities of Port Republic, and
Egg Harbor, the Township of Galloway, all sponsors and producers of this
event, their agents, officiers, employees, volunteers, event directors
and event holders and anyone associated in any way with the event, from
all liabilities, actions, claims, demands, damages, costs and expenses
which I may now or in the future have against them arising out of my participation
in the above mentioned Jersey Genesis Triathlon, including but not limited
to all injuries that may be suffered by me. I attest and verify that to
the best of my knowledge, my physical condition and fitness are adequate
for me to safely compete in the triathlon mentioned above and that no physicans
or other individual has advised me against competing in any part of the
triathlon.
I ceritfy that I have read this document and attest
to its contents.
signature ____________________________________________
date __________
( signature of parent if under 18)