* First Name
* Last Name

* Address

* City

* State
* Zipcode
* Email
* Phone
* T-shirt Size

* Notes: (All entrants must complete a form and sign this release to participate.)

In consideration for accepting this entry and granting the right to participate in this event, I hereby agree for myself, my heirs, my executors and administrators to waive any and all rights and any claims for losses and damages I may have against the sponsors, coordinating groups and individuals associated with the event, their representatives, successors and assigns, and will hold them harmless for any and all injuries suffered in connection with the said event.

Also, none of the above are responsible for the loss of personal items or any form of aggravation in connection with the said event. I represent and affirm that I am in proper physical condition to participate in this event verified by a licensed physician, and have sufficiently trained for the completion of this event.

I give my permission for the free use of my name and picture in any broadcast, telecast or print media account of this event. I also hereby consent to permit emergency treatment in the event of injury or illness. The undersigned has read and voluntarily signed this release and waiver.

 I agree

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