Run/Walk/Ride Sign Up

Leon Deraps 5 mile Memorial Run/Walk/Ride

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Participant Information

Name:  _____________________________________

Address:  ___________________________________

City, State, Zip:  ______________________________

T-Shirt Size:  _________________________________

Participation Waiver:

In signing this release, I acknowledge that I understand the intent thereof and I hereby release, absolve, and hold harmless the Leon Deraps Scholarship Fund or any other parties connected with this event in any way, singly of collectively from and against blame and liability for any death, injury, misadventure, harm, loss, inconvenience or damage hereby suffered or sustained as a result of my participation in the 2009 Leon Deraps Memorial Scholarship Run/Walk/Ride Event or any activities associated therewith.  I hereby consent to and permit emergency treatment in the event of illness or injury.  I also, give full permission for us of my name and/or photo in connection of this event. 

If signed by a parent, the parent agrees to release and hold the above name organization and persons harmless of any claims, which may be asserted by or on behalf of the entrant.

Signature of participant:________________________________________________

Signature of guardian if under 18:  ________________________________________

Date:  ______________________________________________________________

Participation Waiver:

In signing this release, I acknowledge that I understand the intent thereof and I hereby release, absolve, and hold harmless the Leon Deraps Scholarship Fund or any other parties connected with this event in any way, singly of collectively from and against blame and liability for any death, injury, misadventure, harm, loss, inconvenience or damage hereby suffered or sustained as a result of my participation in the 2009 Leon Deraps Memorial Scholarship Run/Walk/Ride Event or any activities associated therewith.  I hereby consent to and permit emergency treatment in the event of illness or injury.  I also, give full permission for us of my name and/or photo in connection of this event. 

If signed by a parent, the parent agrees to release and hold the above name organization and persons harmless of any claims, which may be asserted by or on behalf of the entrant.

Signature of participant:________________________________________________

Signature of guardian if under 18:  ________________________________________

Date:  ______________________________________________________________

Participation Waiver:

In signing this release, I acknowledge that I understand the intent thereof and I hereby release, absolve, and hold harmless the Leon Deraps Scholarship Fund or any other parties connected with this event in any way, singly of collectively from and against blame and liability for any death, injury, misadventure, harm, loss, inconvenience or damage hereby suffered or sustained as a result of my participation in the 2009 Leon Deraps Memorial Scholarship Run/Walk/Ride Event or any activities associated therewith.  I hereby consent to and permit emergency treatment in the event of illness or injury.  I also, give full permission for us of my name and/or photo in connection of this event. 

If signed by a parent, the parent agrees to release and hold the above name organization and persons harmless of any claims, which may be asserted by or on behalf of the entrant.

Signature of participant:________________________________________________

Signature of guardian if under 18:  ________________________________________

Date:  ______________________________________________________________