2009 Daniel Burnham Open 4,000m Run – Cricket Hill – December 20th, 2009
THIS EVENT IS PRESENTED FREE OF CHARGE BY
Given:______________________________ M.I.:_______ Family:______________________________
Street:_______________________________________________________________________________
City:_______________________________ State:______ Zip:__________ Country:________________
e-mail:_______________________________________________________________________________
Select: MALE / FEMALE Date of Birth:______________ Age on 12/20/2009:____________
Team affiliation:________________________________________________________________________
RELEASE FORM: I am aware that serious injury including death may occur while participating in a running event and that I and/or my child should not enter and participate in the Event unless physically able. I agree to abide by the rules and decision of any Event official relative to me and/or my child’s ability to safely complete the event. I will provide adult supervision for my child to, during, and from the event. I assume all risks associated with my and/or my child’s participation in the 2009 Daniel Burnham Open 4,000m Run. Having read this waiver and release from liability form, and in consideration of your accepting my entry and/or my child’s entry, I, for myself and/or my child and anyone entitled to act on our behalf, waive and release Lee Greenberg, Daniel C. Kittaka, Mark Wehrman, race day volunteers, all event sponsors, their representatives and successors from all claims or liabilities of any kind arising from my participation and/or my child’s participation in this event.
Signature: __________________________________________________ Date:___________________
Parent/Guardian if participant is under 18
