June 4, 2016 - REGISTRATION FORM First Name Last Name Date of birth (mo dy yr) Email Street Address City State Phone Zip code Gender Age I am joining a team __________________________________ _____________________________________________ Captain Name Team Name CHOOSE AN EVENT: 5K Competitive Run/Walk (with timing tag) REGISTER IN ADVANCE: Small TEAM & INDIVIDUAL pre-registration 5K Non-competitive Run/Walk (no timing tag) Large X-Large Day of event: $25 without a t-shirt 2X-Large In addition to my entry fee, I wish to make a donation to ICADV to end domestic violence. $ TOTAL $ METHOD OF PAYMENT Card Number Check payable to ICADV VISA Pre-registration packet pickup (optional) June 3, 2016, 8 am - 6 pm at ICADV $25 includes a t-shirt (indicate size below) $20 without t-shirt $15 Youth Group includes a t-shirt (indicate size below) Medium Deadline June 2, 2016, 12 noon 5K Wheelchair Roll Mastercard Exp. Date Name as it appears on card Discover Signature WAIVER — MUST BE SIGNED Participant, including Participant’s parent or guardian if a minor child (collectively “Participant”), understands that there are certain risks, including risks of serious personal injury, property damage or fatal injury, when participating in a road race such as the Race Away From Domestic Violence (the “Race”). Such risks include, without limitation, negligence of the Released Parties, the conditions of related facilities, equipment failure, known or unknown medical conditions, and/ or acts of others. Participant voluntarily assumes all risks that may be connected with participation in the Race and acknowledges that Participant is voluntarily participating with knowledge of these risks. The term “Released Parties” shall include Indiana Coalition Against Domestic Violence (the “ICADV”), Victory Field, Tuxedo Brothers, the City of Indianapolis, race sponsors, and race officials, as well as their employees, volunteers, agents, representatives, affiliates, independent contractors, and any person associated in any way with the Race or Participant’s participation in the Race. Participant RELEASES AND DISCHARGES the Released Parties from and against all claims, damages, injuries, losses, actions, suits, proceedings, strict liability actions, wrongful death actions, expenses, and attorney fees that Participant or anyone on Participant’s behalf (which includes but is not limited to heirs, representatives or next of kin) have or might have for any fatal injuries, injury, claimed injury, or property damage arising out of or relating to Participant’s participation in the Race, including, but not limited to, any claim that the act or omission complained of was caused in whole or in part by the strict liability or negligence in any form of any of the Released Parties. Participant further agrees to INDEMNIFY, HOLD HARMLESS, AND DEFEND the Released Parties in any action or proceeding related to any such claim(s). I have read and fully understand this Release of Liability and Agreement to Indemnify and agree to be bound by its terms. I understand that by signing this document I am waiving certain legal rights, including the right to sue the Released Parties. If I am signing this Release as the parent or guardian of a minor who will be participating in the Race, I represent that I am the legal guardian of the minor and give my permission for his or her participation. Participant agrees to abide by all Program rules and will follow all oral or written instructions and directions given by the Released Parties. In no case will such rules or instructions modify this waiver and release. Signature of Participant Participant further expressly grants to the ICADV, and any other Person authorized by the ICADV, the perpetual right to photograph and film the Race and to use Participant’s photographs, likenesses and biographical material in any and all media, and in any manner or medium whatsoever, for purposes of advertising, grant proposals, promotion and trade materials of the ICADV throughout the world, without payment of any compensation of any kind to Participant or any other Person and without any liability to any Person. For purposes of this agreement, the term “Person” shall mean any natural person, legal entity, or other organized group of persons or entities. 1915 W. 18th St., Suite B Indianapolis, IN 46202 317.917.3685 Signature of Parent/Guardian if entrant is under age 18 PLEASE NOTE: The 5K will be held rain or shine. Complete this form, one per participant. Credit card, check or money order payments are accepted. MAIL ENTRIES TO: Tuxedo Brothers, 6265 Boone Ridge, Zionsville, 46077. FAX ENTRIES TO: 317-873-5803 You may also register online at www.icadvinc.org. Copies of the registration form will be accepted.
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