Indoor Track Participation Request 2008

Athlete Information

 
First Name Last Name
Address: City
State Zip
Date of Birth (mm/dd/yyyy) Home Phone
Parents Name (First and Last) Mobile Phone
Meet Interested In:    
Events Interested In:

In consideration of your accepting my entry, I, intending to be legally bound, do hereby for myself, my heirs and my executors and administrators, waive and release forever any and all rights and claims for damages I may accrue against all persons and agencies Namely: Derby City Athletic Club, Meet Hosts or Promoters and any others promoting the races as listed by name, their successors, representatives, and assigns for any and all injuries suffered by me while traveling to and from and while participating in these events. I hereby represent that I have full knowledge of the risks involved in these events and that I am sufficiently trained and physically fit to participate.

Initials of Parent or Legal Guardian