Full Name:
Address:
Address:
City:
State:
Phone:
E-mail:
Zip:
In consideration of the foregoing, I, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for any claims damages I may have against any of the sponsors, speakers, volunteers, organizers, City of Shelbyville, Shelby Co. Shelbyville Library, Energy2Action, LLC, and The Shelby Roadrunners, for any and all claims of damages, demands or loss actions whatsoever which may arise as a result of my participation in this training program and are more fully described below. I understand and acknowledge that participating in this program may expose me to dangers from both known and anticipated risks. I acknowledge that I could be at risk from traffic, other runners and cyclists, bad weather, ice and rough terrain along the run courses or on my way to class. I attest and verify that I am physically fit and have sufficiently trained for the completion of this program and my physical condition has been verified by a licensed medical doctor. I understand that I may incur permanent injury and I agree that I will monitor my own needs and progress and will not hold any other party responsible for any injury that I may incur. I understand that this program may be canceled or delayed for any legitimate purpose or reason and that my entry fee will not be refunded under those circumstances or for any other reason. Further, I grant full permission to any and all of the foregoing to use my likeness for any legitimate purpose whatsoever.
Age on 1/5/10:
Begins January 5, 2010
6:00 p.m.
Shelby Co.-Shelbyville Library
57 W. Broadway
Shelbyville, IN 46176
Registration is due by 12/31/09
$30.00
All credit card payments are received on line through Pay Pal, a reputable and secure payment center. No entity or individual is given access to your credit card information other than Pay Pal - not even Energy2Action. Please note that there is a $1 fee for processing through PayPal.
