Relay For Life
Youth Registration Form
& Parent/Guardian
Waiver Indemnity
28 – 29 March 2015
Casino
*Create a Team & Become Team Captain
*Team Name
*Join a Team as a Participant
Did you participate in Relay For Life in 2014?
Yes
LO ConsID (office use only)
No
Youth Contact Details (Please Print Legibly)
*Title:
Mr
Mrs
Ms
Miss
Other_______
*First Name: ____________________________ *Last Name: ______________________________
*Postal Address: __________________________________________________________________
*Town/Suburb: _______________________________ *State: _________ *Postcode: ___________
*Mobile: __________________________ Home Phone: __________________________________
*Email: _________________________________________________________________________
Sex:
M
F
*DOB: _____/_____/__________ (DD/MM/YYYY)
*Parent / Guardian Details
If a participant is under the age of 18, a parent or guardian must sign the parent/guardian waiver & indemnity on the
reverse side of this form. The parent/guardian will be contacted by Cancer Council NSW to keep them informed of Relay
For Life updates and future events or activities on behalf of the youth participant. In addition, the parent/guardian will be
responsible or will organise an adult supervisor for the youth participant at the Relay and ensure any necessary banking
is completed by the youth participant after the event.
*Title: ______ *First Name: ______________________ *Last Name: _______________________
*Mobile: _________________________ Home Phone: __________________________________
*Email: _________________________________________________________________________
*Fundraising Goals
Relay For Life Event Shirt
(We ask everyone to aim to raise a
minimum of $150 per participant)
Would you like an event shirt?
Yes
No
Youth Shirt Size:
Personal Fundraising Goal:
6
8
10
Adult Shirt Size:
$
Team Fundraising Goal:
S
M
L
XL
2XL
3XL
4XL
5XL
$
Thanks to the help and support of fundraisers like you, more than 60% of all cancer cases in NSW are now successfully treated.
Relay For Life Terms & Conditions of Participation
Any registration of a youth (under 18) participant will be considered provisional until this form is signed by that youth participant’s
parent or guardian and given to an authorised Cancer Council NSW (Cancer Council) representative. ‘Relay For Life’ includes not only
the Relay For Life event, but all other activities relating to Relay For Life, whether occurring before, during or after the event, and
whether organised by Cancer Council or any other person.
I am the parent/guardian of the youth participant named above
(Youth Participant).
Risk Notice and Voluntary Assumption of Risk
Relay For Life is an event that involves physical exertion and as such has
certain inherent risks associated with it. Some of those risks are injury due to
slippery or uneven surfaces, obstacles, trip hazards, overcrowding, collision
with objects or people and the effects of heat, cold, dehydration and
exhaustion. In rainy, windy or other inclement weather conditions, tents,
marquees or other structures may collapse or become unsecured from the
ground, potentially resulting in injury. Further risks may be associated with
parts of Relay For Life that may occur at night.
Injuries may include injuries from falls such as broken bones, sprained
muscles, injuries to ligaments, cartilage or other soft tissue, as well as blisters,
cuts and abrasions. Injuries may also arise from exertion, including heart
attack, fainting and loss of consciousness. I understand that the risks of
participation in Relay For Life are increased if the Youth Participant chooses to
participate in costume, in novelty shoes, using props, or if his/her walking or
running movement is restricted. I accept these increased risks if I allow the
Youth Participant to participate in Relay For Life in this manner.
The Youth Participant and I acknowledge that the above is not an exhaustive
list of all risks inherent in my participation in Relay For Life. The Youth
Participant and I further acknowledge that there may be risks that are not
known or reasonably foreseeable at this time.
I understand that Cancer Council recommends that the Youth Participant
consults a doctor before participating in Relay For Life, particularly if he/she
has ever experienced a heart condition, stroke, unexplained chest pains,
faintness, dizziness, shortness of breath, severe asthma, diabetes, muscle,
joint or bone problems or any other medical conditions that may make it
dangerous for him/her to participate in Relay For Life.
Regardless of whether he/she has consulted a doctor, I agree that by allowing
the Youth Participant to participate in Relay For Life, I am aware of the risks
involved and I voluntarily assume those risks (including any arising from the
negligence of Cancer Council).
I warrant that the Youth Participant has no known medical conditions or
disabilities that may be incompatible with his/her safe participation in Relay For
Life. I warrant that the Youth Participant is in proper physical and mental
condition to participate in Relay For Life.
I understand that Cancer Council has obtained no personal accident insurance
or any other insurance covering the participation by the Youth Participant in
Relay For Life and it is my responsibility to obtain any and all insurance which
is appropriate for that purpose.
I understand that Cancer Council will not supervise the Youth Participant and
the he/she must be supervised by me or an adult arranged by me.
I acknowledge that during Relay For Life both the person and property of the
Youth Participant shall be at my own risk.
Waiver and indemnity
In consideration of the Youth Participant being permitted to participate in Relay
For Life, on my own behalf and on behalf of the Youth Participant, I fully and
irrevocably exclude and release Cancer Council and all Relay For Life
sponsors, as well as their directors, officers, employees, volunteers, agents
and representatives, from all liability for any loss, damage, cost or expense
(whether in negligence, contract, under statute or otherwise) suffered by the
youth participant as a consequence of his/her involvement in Relay For Life,
including in relation to death and personal injury.
I further agree that if any claim, including in relation to personal injury, property
damage or wrongful death arising from the Youth Participant’s participation in
Relay For Life is commenced, I will indemnify and hold harmless Cancer
Council and all Relay For Life sponsors, as well as their directors, officers,
employees, volunteers, agents and representatives, from any and all loss,
damage, cost or expense in connection with such claim.
Exclusion of Cancer Council’s liability
I understand and agree that to the maximum extent permitted by law:
• all conditions, warranties, guarantees, rights, remedies, liabilities or other
terms implied or conferred by statute, custom, or the general law that impose
any liability or obligation on Cancer Council or Relay For Life sponsors (or
their directors, officers, employees, volunteers, agents and representatives)
are excluded (including consumer guarantees to the extent such exclusions
are permitted under the law);
• neither Cancer Council nor any Relay For Life sponsor (nor any of their
directors, officers, employees, volunteers, agents and representatives) will
be liable to me, the Youth Participant or any other person in contract, tort
(including negligence) or otherwise for any loss, damage, cost or expense of
any kind (including direct, indirect or consequential losses, damages, costs
and expenses) suffered or incurred by me, the Youth Participant or any other
person in connection with Relay For Life; and
• in any circumstances where the above exclusions (or any of them) are held
by a Court to be ineffective or unenforceable for any reason whatsoever,
Cancer Council’s liability to the Youth Participant, to me and to any other
person is limited (at its option) to resupplying, repairing or replacing the
service or the payment of the cost of supplying the service to the Youth
Participant and me again.
Photographic consent
I acknowledge that in the course of Relay For Life, photographs, images or film
may be taken of the Youth Participant, either alone or in group shots with
others. I agree to the use of the Youth Participant’s image in these
photographs, images or film and for their use on the websites or in Cancer
Council publications in the future. I agree to the use of the Youth Participant’s
name in conjunction with any photographs of him/her. I also agree that the
photographs or film may be used by third party media organisations in
connection with the reporting of Relay For Life.
Privacy
I understand that Cancer Council collects two types of information through this
website:
1. Personal information that I provide; and
2. Standard web server/visitor traffic information such as ISP addresses,
browser versions, referring websites, duration of visits and total visitor traffic.
This information helps Cancer Council to understand how people use its
website and assists Cancer Council to manage its site to better serve its
audience.
I consent to the collection of my personal information including my first name
and surname, email address, physical address and telephone number, as well
as information about my health and lifestyle. I consent to the use of such
information (and other related information) for the purpose of providing me with
email reminders, telephone call-backs and SMS messages, as well as to
evaluate, develop, improve and promote Relay For Life and other Cancer
Council events and fundraising offers and opportunities. I consent to the
disclosure of this information to third parties for the purpose of providing
automated SMS messages to me.
I understand that information may be disclosed to third parties outside
Australia including offshore parties, to facilitate these activities and for the
purpose of data storage and back-up, and that these third parties may be
located in countries that have different privacy laws and standards from those
that exist in Australia. I consent to such disclosure of my personal information.
More information on privacy is available in the Cancer Council Privacy Policy,
a copy of which is available on request.
Parent/Guardian Name: _______________________________________________________________________________________
Parent/Guardian Signature: ___________________________________________ Date: ____________________________________
OFFICE USE ONLY
Registration Paid:
Yes
No
N/A
Terms & Conditions Signed:
Yes
No
Amount Paid: ______________
Promo Code: ______________
Signature: ____________________________________________________________
Paid By:
Cash
Card
Date: ___________________________