Transcript BAL VIHAR 5K WALK/RUN April 6, 2014 Millennium Park, Creve

BAL VIHAR 5K WALK/RUN
Registration Form:
April 6, 2014
Millennium Park, Creve Coeur
Participant 1: _________________
Participant 2: _________________
Participant 3: _________________
Participant 4: _________________
Participant 5: _________________
Participant 6: _________________
Participant 7: _________________
1K
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3K
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5K
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5K+
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WAIVER AND RELEASE
I hereby declare, assert and affirm that my participation in the Center of Indian Cultural Education, Bal Vihar of
St. Louis, 5K Walk/Run is done voluntarily and knowingly, assuming ALL RISKS involved in this Event. I hereby
certify the following: I am physically fit and have received medical clearance to participate in the Run/Walk. I
recognize that the immediate physical risks and hazards associated with normal, vigorous physical activity
include (but are not limited to) physical discomfort, fatigue, muscular soreness, falls, pulled or strained muscles,
overuse injuries, heat stress, and the rare instance of abnormal responses of the cardiorespiratory system
including heart arrhythmia, heart attack, stroke, and sudden death. If I do participate, I, on behalf of myself, my
heirs and assigns, and my estate, hereby Waive and Release and forever discharge the sponsors, organizers,
affiliates specifically Center of Indian Cultural Education, Bal Vihar of St. Louis, their respective volunteers, as
well as their agents and employees, from any and all claims that may occur as a result of my participation. I
hereby give my permission to the event organizers and sponsors to use my name and/or picture in any
publication, broadcast, telecast or other account of this event without limitation or obligation of further
compensation thereof. By signing this waiver and release I certify that I fully understand its significance.
_______________________________ Date _________ / _____________________________ Date_________
Participant #1 signature
If under 18, Parent or Guardian’s signature
_______________________________ Date _________ / _____________________________ Date_________
Participant #2 signature
If under 18, Parent or Guardian’s signature
_______________________________ Date _________ / _____________________________ Date_________
Participant #3 signature
If under 18, Parent or Guardian’s signature
_______________________________ Date _________ / _____________________________ Date_________
Participant #4 signature
If under 18, Parent or Guardian’s signature
_______________________________ Date _________ / _____________________________ Date_________
Participant #5 signature
If under 18, Parent or Guardian’s signature
_______________________________ Date _________ / _____________________________ Date_________