Application Form (please type or print

Application Form (please type or print)
Name______________________________________________ Which Route? 12, 26, or 42 Miles
Mailing Address ___________________________________________________
City ______________________State _______ Zip ________________
E-mail _______________________________________ Daytime Phone: _________________
Sex: _______ Date of Birth ____/____/____
T-shirt Size (circle one) S
M
L
XL
XXL
Emergency Name/Phone Number_________________________________________________
How did you hear about our event? ________________________________________________
Type of Registration or Donation
Cost
Individual
$60
Team Member*
$55
Team Name: __________________________________
Child 12 and Under Registration
(One Child 12 and under may ride FREE with paid adult entry.
Additional children 12 and under can be registered for $20 each.
All registrations include a moisture wicking shirt and cinch bag.)
First Name
Last Name
Sex Age Child’s T-Shirt
Size (circle one) Cost
S M L
Free
S M L
$20
S M L
$20
S M L
$20
S M L
$20
Additional Donation to The Tree House
TOTAL DUE:
* If team does not already exist you must submit a minimum of 10 registrations to create
the team at the time you submit this form.
Please submit your completed application with payment in full to:
The Tree House CAC
7300 Calhoun Pl, Suite 600
Rockville, MD 20855
Please make checks payable to: The Tree House CAC
Total
$
$
Free
$
$
$
$
$
IN ORDER TO REGISTER AND PARTICIPATE IN THIS ATHLETIC EVENT, YOU
MUST READ, UNDERSTAND AND AGREE TO THE FOLLOWING
ACCIDENT WAIVER AND RELEASE OF LIABILITY.
WAIVER
Accident Waiver and Release of Liability and Registration Agreement
By signing below, you agree, warrant and covenant as follows:
1. Authority to Register and/or to Act as Agent. You REPRESENT AND WARRANT to
The Tree house Child Assessment Center (Tree House) that you have full legal authority
to complete this event registration, including full authority to make use of the credit or
debit card to which registration fees will be charged. In addition, if you are registering
third parties, you represent and warrant that you have been duly authorized to act as agent
on behalf of such parties in performing this event registration. By proceeding with this
event registration, you agree that the terms of this Accident Waiver and Release of
Liability and registration agreement shall apply equally to you and to any third parties for
whom you are acting as agent.
2. Compliance with Children's Online Privacy Protection Act (COPPA). You represent
and warrant that, in compliance with COPPA, you are over thirteen (13) years of age, and
that if you are registering a child under fourteen (14) years of age you are the parent of
such child, and do hereby consent to the collection of such child's personal information
by TREE HOUSE.
3. Acknowledgment of RISKS. I acknowledge that this athletic event is an extreme test of
a person's physical and mental limits and carries with it the potential for death, serious
injury and property loss. The RISKS include, but are not limited to, those caused by
terrain, facilities, temperature, weather, condition of athletes, equipment, vehicular
traffic, actions of other people including, but not limited to, participants, volunteers,
spectators, coaches, event officials, and event monitors, and/or producers of the event,
and lack of hydration. These risks are not only inherent to athletics, but are also present
for volunteers. I hereby assume all of the risks of participating and/or volunteering in this
event. I realize that liability may arise from negligence or carelessness on the part of the
persons or entities being released (as stated below), from dangerous or defective
equipment or property owned, maintained or controlled by them or because of their
possible liability without fault.
I CERTIFY that I am physically fit, have sufficiently trained for participation in the event
and have not been advised otherwise by a qualified medical person. I CERTIFY that I
will properly wear a CPSC approved bicycle helmet. I understand and CERTIFY that I
must obey all laws of the State of Maryland which may apply to my activities during this
event, especially traffic laws. All traffic signals, devices, and other traffic rules apply to
me during this event. Unless instructed to the contrary by a law enforcement official, I
must comply with all traffic regulations.
4. Acknowledgment of WAIVER. I acknowledge that this Accident Waiver and Release
of Liability (AWRL) form will be used by the event holders, sponsors and organizers, in
which I may participate and that it will govern my actions and responsibilities at said
events.
In consideration of my application and my participation in this event and related
activities, I hereby take action for myself, my executors, administrators, heirs, next of
kin, successors, and assigns as follows: (A) WAIVE, RELEASE AND DISCHARGE
from any and all liability for my death, disability, personal injury, property damage,
property theft or actions of any kind which may hereafter accrue to me THE
FOLLOWING ENTITIES OR PERSONS: TREE HOUSE, Primary Care Coalition of
Montgomery County, Montgomery County Health and Human Services, Montgomery
County Government, Johns Hopkins University, all sponsoring or co-sponsoring
companies or individuals related to the Event, together with their officers, directors,
managers, members, shareholders, successors and assigns, and any and all governmental
and tribal agencies and any and all event sponsors, event beneficiaries, event directors,
event volunteers, and each of their respective directors, officers, employees, volunteers,
representatives, agents, successors, and assigns; (B) INDEMNIFY AND HOLD
HARMLESS the entities or persons mentioned in this paragraph from any and all
liabilities or claims made by other individuals or entities as a result of any of my
participation in this event and any related activities.
I hereby CONSENT to receive MEDICAL treatment which may be deemed advisable in
the event of injury, accident and or illness during this event.
I understand that at this event or related activities, I and/or my children may be
photographed. I AGREE to allow all of these photos, videos or film images to be used for
any legitimate purpose by the event holders, producers, sponsors, organizers and or
assigns.
I understand that I will be added to The Tree House email list, but I may unsubscribe at
any time.
This AWRL shall be construed broadly to provide a RELEASE and WAIVER to the
maximum extent permissible under applicable law.
5. INDEMNIFICATION. You AGREE to INDEMNIFY and hold each of TREE HOUSE
and its officers, employees, volunteers, agents, and any other person associated with this
activity on behalf of TREE HOUSE harmless from any claim or demand, including
reasonable attorneys' fees, made by any third party due to or arising out of your use of
TREE HOUSE’s registration website, your participation in this event, or the violation of
any term of this AWRL or the TREE HOUSE Terms of Service by you.
6. WEBSITE Limitation of Liability; Disclaimer of Warranties. TREE HOUSE SHALL
NOT BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL OR
CONSEQUENTIAL DAMAGES, RESULTING FROM (A) THE USE OR THE
INABILITY TO USE TREE HOUSES REGISTRATION WEBSITE OR (B)
RESULTING FROM UNAUTHORIZED ACCESS TO OR ALTERATION OF YOUR
TRANSMISSIONS OR DATA, INCLUDING BUT NOT LIMITED TO, DAMAGES
FOR LOSS OF PROFITS, USE, DATA OR OTHER INTANGIBLE, EVEN IF TREE
HOUSE HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. YOU
EXPRESSLY AGREE THAT USE OF TREE HOUSE’S REGISTRATION WEBSITE
IS AT YOUR SOLE RISK. TREE HOUSES REGISTRATION WEBSITE IS
PROVIDED ON AN "AS IS" AND "AS AVAILABLE" BASIS. TREE HOUSE
EXPRESSLY DISCLAIMS ALL WARRANTIES OF ANY KIND, EXPRESS OR
IMPLIED, INCLUDING WITHOUT LIMITATION ANY WARRANTY OF
MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE OR NONINFRINGEMENT.
TREE HOUSE makes no warranty that the TREE HOUSE website services will be
uninterrupted, secure or error free. TREE HOUSE does not guarantee the accuracy or
completeness of any information in, or provided in connection with, the TREE HOUSE
website. TREE HOUSE is NOT responsible for any errors or omissions, or for the results
obtained from the use of such information. You understand and agree that any material
and/or data downloaded or otherwise obtained through the use of the TREE HOUSE
website is at your own discretion and risk and that you will be solely responsible for any
damage to your own computer system or loss of data that results from the download of
such material and/or data.
7. NO REFUNDS, NO TRANSFERS. I understand that ALL amounts paid and
contributions collected are NOT REFUNDABLE and are NOT TRANSFERABLE to
another person or event. Rider numbers and timing devices assigned for the event are
NOT TRANSFERABLE to another person.
8. APPLICABLE LAW; Consent to JURISDICTION. The TREE HOUSE sites
(excluding linked sites) are controlled by TREE HOUSE from its offices within the State
of Maryland, United States of America. By completing this event registration, both you
and TREE HOUSE agree that the statutes and laws of the State of Maryland, without
regard to the conflict of laws principles thereof, will apply to all matters relating to this
event registration, this Accident Waiver and Release of Liability, or other use of the
TREE HOUSE sites. You AGREE that exclusive jurisdiction for any dispute with TREE
HOUSE resides in the courts of the State of Maryland and you further agree and
expressly consent to the exercise of personal jurisdiction in the courts of the State of
Maryland in connection with any dispute including any claim involving TREE HOUSE
or its affiliates, subsidiaries, employees, contractors, officers, directors,
telecommunication providers and content providers. You AGREE that venue shall be
exclusively in Montgomery County, Maryland.
9. Severability. If any provision of this Accident Waiver and Release of Liability shall be
unlawful, void, or for any reason unenforceable, then that provision shall be deemed
severable from this Accident Waiver and Release of Liability and shall not affect the
validity and enforceability of any remaining provisions.
10. READ CAREFULLY. This is your CONTRACT for Accident Waiver and Release of
Liability. You are encouraged to obtain the advice of legal counsel before signing and
agreeing to this Contract.
I HEREBY CERTIFY THAT I HAVE READ THIS DOCUMENT AND I
UNDERSTAND ITS CONTENT. I HEREBY CERTIFY THAT I KNOWINGLY AND
WILLINGLY AGREE TO THIS ACCIDENT WAIVER AND RELEASE OF
LIABILITY.
Date______________
Signature______________________________________