Date: Saturday, May 16th, 2015 Time: 9:00 am Location: Keva Sports Center www.mcmsfoxtrot.com Name Date of Birth Run Segment (1 mile or 5K or Kiddie Dash) T-shirt size* Registration Fee* Total amount enclosed $ Email Address* *T-shirt: Size selections can be made if registration is done before May 1st, 2015. Post May 2nd, T-shirts will be available only on first-come-first-served basis *Registration Fees: $12.50 for the 1 mile segment ($5 more on the day of the race) $25 for the 5K segment ($5 more on the day of the race) $22 for 5K group of 5 or more ($5 more on the day of the race) Kiddie Dash – Free If registering through active.com, an additional handling fee of $3.25 will be charged *Email Address: If you would like to receive communication about future events/races at MCMS, please leave us your email address. Your email address will never be published or shared. NOTE: You can either register online at active.com or mail a registration form along with a check made out to Madison Community Montessori School to this address: Madison Community Montessori School Attention: Amanda Viviani 8406 Ellington Way Middleton, WI 53562 Waivers: Please read through the following information and sign at the bottom. Every adult participant needs to sign the waiver and also sign waivers on behalf of children listed in the application. By entering this event, each participant agrees to abide by and be bound by these Official Rules. In the event of Acts of God or other events that prevent the activity on the designated date, the organizers will have the right to extend, suspend or terminate the activity with no additional obligation. All participants release the race organizers, sponsors and other partners and MCMS from responsibility and any liability for any injury, losses or damages of any kind incurred by the participant or any other person as a result of participation in this event. This event will be held rain or shine. I understand that I am completely liable for any actions of each child listed above during participation in the event. I understand that MCMS Fox Trot Family Fun Run is intended to promote healthy activities but that there are risks of injury with any physical activity. I release MCMS, MCMS Fox Trot Family Fun Run organizers, sponsors and all other partners in this event from responsibility and any liability for any injury, losses or damages of any kind incurred by a child or me or any other person as a result of participation in this event. I certify that the above information is correct. I have read, understood and agree to the Official Rules listed above. ____________________ ____________________ ___________________ ____________________ __________________ Adult Participant Adult Participant For Child 1 For Child 2 For Child 3 RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT In consideration of participating in My First Sports LLC's and Keva Sports Center LLC’s programs and activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability My First Sports LLC and Keva Sports Center LLC arising from negligence, and its owners, directors, officers employees, agents, volunteers, participants, and all other persons or entities acting for them (hereinafter collectively referred to as “Releasees”), on behalf of myself and my children, parents, heirs, assigns, personal representatives and estate, and also agree as follows: 1. I acknowledge that participating in My First Sports LLC's and Keva Sports Center LLC’s activities, or acting as an observer of My First Sports LLC's and Keva Sports Center LLC’s activities involves known and unanticipated risks which could result in physical or emotional injury, paralysis or permanent disability, death, and property damage. Risks include, but are not limited to, broken bones, torn ligaments, bruises, pain, or injuries as a result of exercise, physical activity; medical conditions resulting from exercise physical activity; paralysis, and/or damaged personal property. I understand such risks simply cannot be eliminated, despite the use of safety equipment, without jeopardizing the essential qualities of the activity. 2. I expressly accept and assume all of the risks inherent in this activity or that might have been caused by the negligence of the Releasees. My participation in this activity is purely voluntary and I elect to participate despite the risks. In addition, if at any time I believe that event conditions are unsafe or that I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation. 3. I voluntarily release, forever discharge, and agree to indemnify and hold harmless Releasees from any and all claims, demands, or causes of action which are in any way connected with my participation in this activity, or my use of their equipment or facilities, arising from the Releasees’ or my own negligence. This release does not apply to claims arising from intentional conduct. Should Releasees or anyone acting on their behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs. 4. I represent that I have adequate insurance to cover any injury or damage I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or damage myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume – and bear the costs of – all risks that may be created, directly or indirectly, by any such condition. 5. By providing your contact information Keva reserves the right to contact you in regards to future programs at Keva and or to use photos for promotional marketing material for future use. Keva does not sell any personal information to other parties. 6. With full knowledge of the risks of injury in programs at Keva Sports Center, LLC, I hereby authorize, the following persons to administer emergency medical treatment to the Registrant, for any injury or other medical emergency while at a practice, game, tournament, scrimmage, or while participating in or attending any other activity: All coaches and managers of me or my child's team; all officers and officials of Keva Sports Center, LLC programs to which me or my child's team belongs; all directors, officers, sponsors, officials or agents of any league or tournament that Registrant may participate in; and Keva Sports Center LLC staff members. This consent also extends the right to those persons listed above to arrange for immediate medical treatment by a licensed physician and/or other trained medical personnel, and for them to provide such emergency medical care, as they deem appropriate to preserve the life or well being of the Registrant. The Registrant and I (if parent or legal guardian) hereby release, hold harmless and indemnify the above-listed persons of any injury or damage related to administration of emergency medical care as authorized herein. By signing this document, I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence. I have had enough time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain. I have read and understood this document and I agree to be bound by its terms. _________________ _______________ ____________ ____________ ____________ Adult Participant Adult Participant For Child 1 For Child 2 For Child 3
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