Builders Club Earth Day 5K Individual Registration

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Register an Individual for the Builders Club Earth Day 5K

* Indicates required field

Name *

First

Last

Age *

Gender *

Street Address *

City *

Select One *

Zip Code *

Primary Phone Number *

Secondary Phone Number *

Email *

T-Shirt Size *

Waiver and Release of Liability

IMPORTANT WAIVER STATEMENT

For and in consideration of the above-named individual's participation in the above-identified activity/event, the parent(s) or legal guardian(s) of the participant and the undersigned waive, release and/or relinquish any and all claims, rights and causes of action including, but not limited to, claims or causes of actions for personal injury, property damage and/or wrongful death, arising out of the above names individual's participation in the aforementioned activities/event, wherever or however they occur, and for such period said activities/event may continue. By signing this Agreement, all claims, rights, and causes of action that the participant or anyone claiming on behalf of or through participant may have hereby waived, released and/or relinquished, and the participant [or parent(s)/guardian(s)] does (do) so on behalf of my/our and participant's heirs, executors, administrators and assigns.

It is the purpose of this agreement to exempt, waive and release Releasees from any and all liability to the above-named participant or any individual or entity claiming by or on behalf of participant for personal injury, property damage, and wrongful death or any other claim, right, or cause of action, even if such liability, claim, or cause of action is the result of the alleged negligence, if any, of Releasees. Releasees shall include Builders Club of Danville, Kiwanis Club of Danville, Danville Community School Corporation, event hosts, other participants, or volunteers, and their insurers.

In the event of any medical emergency, I authorize the Danville Builders Club officials to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or my minor child for immediate care and agree that I will be responsible for payment of any and all medical services rendered.

Participant and/or participant's parent(s)/guardian(s) acknowledge that they understand and have read each of the above paragraphs and have not relied upon representation of Releasees, that they are fully advised of the potential dangers of the above-mentioned activity/event, and that participant and/or participant's parents/guardians, have all legal authority to sign this Waiver and Release.

I HAVE READ THIS DOCUMENT AND UNDERSTAND THAT IT IS A RELEASE OF ALL CLAIMS. I ACKNOWLEDGE IT AND WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

To be a participant in the Danville Builders Club Earth Day 5K, you will need to agree to this waiver. By checking the box on your below, you will be agreeing to all of the above.

I have read, understand, and agree to the above waiver and release of liability. *

Yes

Electronic Signature

I have read, have understood, and do accept the agreement above.
I understand that this is a legal document with effects that I approve and authorize.
The registrant is the person(s) whose name is submitted as the recipient of the goods and services provided as a result of this transaction.
I am authorized to agree to the terms of this document on behalf of the registrant.
If the registrant is under 18 years of age, incapacitated, or mentally challenged, I assert that I am the parent/legal guardian or otherwise authorized to execute a legally binding agreement on behalf of the registrant.

Electronic Signature

You must be 18 years of age to legally complete this registration. If the registrant is under 18, an authorized adult must complete this form.

If the person you are registering (registrant) is under 18, do not enter his/her age. Enter your age here as the person completing the form.

Your Age *

Provide your electronic signature by typing your name: *

By clicking on the button below, your registration information will be submitted to us, and you'll be sent to PayPal to pay $20. Even if you do not have a PayPal account, you can pay with a credit card through PayPal. Registration is not complete until payment has been made.

Thank you!

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