June 4, 2016 - REGISTRATION FORM

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.