Fill and Sign the Poker Run Form

Waiver, Release and Registration Form for Poker Run to be Held on ________________ (Date) Benefiting __________________________________________ (Name of Description of Charity or Cause) Name of the Activity or Event : __________________________ Poker Run Benefiting ________________________________ (Name or Description of Cause or Charity) Date of Activity or Event : ___________________________ Name of Entrant: ________________________________ Age________ Adult T ‐ Shirt Size_______________ Street or Mailing Address: ___________________________________________ City__________________________ State________ Zip Code____________ Home Phone #: ___________________ Emergency Phone #___________________ E ‐ mail: ________________________________________ [ ] $25.00 Entry Fee has been paid. [ ] $25.00 Entry Fee has not been paid. Waiver, Release of Liability and Indemnity Form The undersigned _________________________ HEREBY ASSUMES ALL OF THE RISKS OF PARTICIPATING AND/OR VOLUNTEERING IN THIS ACTIVITY OR EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released and/or from dangerous or defective equipment or property owned, maintained, or controlled by them. I certify that I am physically fit, have sufficiently trained for participation in this event, and have not been advised otherwise by a qualified medical person. I acknowledge that participating in a Poker Run is potentially a hazardous activity. I assume all risks associated with competing and participating in this event. These risks include, but are not limited to, those caused by terrain, water conditions, weather, lack of hydration, and actions of participants, volunteers, spectators, or producers of this event. I release and discharge from any and all liability, damage, property theft or actions of any participants or my traveling to this event the ________________________ (name of organization) , whose address is _________________________________________________ (street address, city, state, zip code) , all sponsors, event directors, volunteers, and all municipalities in which the event is conducted. I hereby agree to indemnify and hold harmless the persons or entities mentioned in this paragraph from any other activities connected with the Run in which I may participate. I also give full permission for use of my name and photograph in connection with this event. I understand that all entry fees are nonrefundable. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A WAIVER, RELEASE OF LIABILITY AND AN INDEMNITY CONTRACT AND I SIGN IT OF MY OWN FREE WILL. Witness my signature this the ______ day of ________________, 20______. __________________________ (Printed Name of Participant) __________________________ (Signature of Participant) (Parent or guardians signature shall be required if participant is under 18 years of age.) Waiver, Release and Registration Form for Poker Run to be Held on __________________ (Date) Benefiting _______________________ (Name of Description of Charity or Cause) The undersigned ________________________ (Names of Parents or Guardians) , declare that we are the Parents or Legal Guardians of the above named Participant. In such capacity as Parents or Legal Guardians, we acknowledge that we have carefully read this Agreement and we do hereby assume all responsibilities and obligations of Participant as set for therein and do specifically agree to indemnify and hold harmless the ____________________________ (name of organization) , whose address is ______________________________________ (street address, city, state, zip code) , all sponsors, event directors, volunteers, and all municipalities in which the event is conducted a nd join in all waivers and releases of said Agreement. CONSENT AS TO MEDICAL CARE In addition, in the event of an emergency or non-emergency situation requiring medical treatment, the undersigned Parents or Legal Guardians hereby grant permission for any and all medical and/or dental attention to be administered to Participant, in the event of an accidental injury or illness. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. The undersigned request that we be contacted as soon as possible in the case such medical care is necessary or appears to be necessary. WITNESS our signatures as of the ____day of _____________, 20_____. ____________________________ (Printed Name of Parent or Guardian) ____________________________ (Signature of Parent or Guardian) _______________________________ (Printed Name of Parent or Guardian) _______________________________ (Signature of Parent or Guardian)