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