Tenth Annual Lee E. Barta Remembrance Run Entry Form
Name:___________________________________
Address:__________________________________
Print
clearly!
City:____________________________________ State:______ Zip:______ Phone:_____________________
Date of Birth:_______________ Age:_____ Male ______ Female_____ (check one)
(Check if yes)
Clydesdale (225 lbs. & over) _____
Full-time law enforcement officer_____
T-shirt size:
_____Small _____Medium
_____Large _____X-large
(Shirt size guaranteed for pre-registrants only.)
NO BIKES, NO IN-LINE SKATES, NO BABY STROLLERS AND NO DOGS ARE ALLOWED IN THE 5K OR FUN RUN.
R E L E A S E
RELEASE NOTICE: THIS
ENTRY BLANK AND RELEASE IS A CONTRACT WITH LEGAL CONSEQUENCES. READ IT
CAREFULLY BEFORE SIGNING. In consideration of my application for entry in the
above event, I hereby freely agree to and make the following contractual
representations and agreements. I fully realize the inherent dangers of
participating in a road race and fully assume the risks associated with such
participation including, by way of example, and not limitation, the following:
the dangers of collision with pedestrians, vehicles, other racers, and fixed or
moving objects; the dangers arising from surface hazards, equipment failure,
inadequate safety equipment, and weather conditions, and the real possibility
of serious physical and/or mental trauma or injury associated with athletic
running competition. I hereby waive, release and discharge for myself, my
heirs, executors, administrators, legal representatives, assigns, and
successors in interest (hereinafter collectively successors) any all right and
claims which I have or which may hereafter accrue to me against the sponsors of
this event, the promoter and any promoting organization(s), the City of
Binghamton and its Parks and Recreation, and all contributors of cash prizes,
all volunteers who help with the race, property owners, law enforcement
agencies, all public entities, special districts, and properties (and their
respective agents, officials and employees) through or by which the events will
be held, for any damages, including but not limited to any damages resulting
from or arising out of the negligence of any or all of the above-named sponsors
of this event, which may be sustained by me directly or indirectly in
connection with, or arising out of, my participation in or association with the
event, or travel to or return from the event, I will abide by this release
whether or not injury occurs to me in the State of New York and Consent to the
enforceability of this release and express assumption of risk in said state. My
signing of this agreement releases the City of Binghamton and its Parks and
Recreation and all other sponsors, all contributors of cash prizes, volunteers,
government entities and race officials from liability for any act or omission
of theirs, including acts or omissions constituting negligence, in the conduct
of this race which causes me personal injury, death or property damage.
PARENT OR
GUARDIAN of a Minor (minor is defined "under the age of 18 years"):
I, as parent or guardian of the below named minor, hereby give my permission
for my child or ward to participate in the event, and further agree,
individually and on behalf of my child or ward, to the terms of the above.
If you are a Parent/Guardian signing for a minor, please print the name of
the participating minor below:
_________________________________
_________________________________
Signature of participant, or Parent/Guardian
of
Name of Minor
participant if participant is under 18 years of
age.
Please print name underneath signature