Download Report

ALS TDI 5k & Awareness Walk
Sunday, May 3, 2015
Registration opens at 8:30 AM
Technology Square Courtyard
300-500 Technology Square
Cambridge, MA 02139
Walker Registration Form
Full Name
Age
Sex
Billing Address
City
State
Primary Phone
Zip
E-mail Address
Are you participating as part of a Team?
Yes
No
Team Name
Fees: $20 registration fee, fundraising minimum of $25 due 5/31/15 11:59:59 PM.
Post Race Lunch: Complimentary lunch served for runners and walkers
Registration: Opens at 8:30 AM at Technology Square Courtyard, 300-500 Technology Square, Cambridge, MA
Parking: Free at the Technology Square Garage: 800 Technology Square, Cambridge, MA. Please pick up a
parking voucher at registration.
Payment: Checks can be made payable to
ALS Therapy Development Institute, R4R 5K
300 Techonology Square, STE 400, Cambridge, MA 02139
I understand that it is my responsibility to raise a minimum of $25.00 in donations for ALS TDI before the close of fundraising
for this event. I understand that if I do not raise the required fundraising minimum by May 31, 2015 I will be invoiced for the
balance.
Signature of Participant
Date
Signature of Guardian (If under 18)
Date
www.Race4Research.org
ALS Therapy Development Institute; Cambridge, MA 02139 (p)617-441-7200
ALS Therapy Development Institute
ALS TDI EVENT WAIVER AND RELEASE
I wish to participate in the Race 4 Research, an ALS Therapy Development Institute event. I understand that by participating in the event, I will
be using public streets and facilities where many hazards exist and will subject myself to the danger of harm inherent in such an event. I am
aware of and appreciate the many risks that exist and the many adverse consequences that may occur as a result of my participation in the event,
including but not limited to, accidents, property damage, serious personal injury and even death. I am voluntarily participating in this event with
full knowledge of the dangers involved and agree to accept all risks of damage, injury and death.
To the extent that I am participating in the event with a minor under 18 years of age, each such minor is either my child or I am the legal guardian
of such minor, and I agree to accompany each such minor during the entire event. I and each such minor are aware of and appreciate the many
risks that exist and the adverse consequences that may occur as a result of such minor’s participation in the event, including but not limited to,
accidents, property damage, serious personal injury and even death. I and each such minor are voluntarily participating in this event with full
knowledge of the dangers involved and agree to accept all risks of damage, injury and death.
On behalf of myself and any minor with whom I am participating in the event, I agree to assume all risks and to release and hold harmless the
ALS Therapy Development Institute and its staff, the event Medical Director and/or the event medical team, as well as all other event sponsors,
officials, volunteers, participating clubs, communities, organizations and friends of the event from and against any and all claims that I or any
minor with whom I am participating may have as a result of the event. I also agree to release and hold harmless all government or public entities
including, but not limited to, the applicable Departments of Transportation and affiliated organizations (and all their respective directors, officers,
agents, employees and members), who, through negligence, carelessness or any other cause might be liable to me or any minor with whom I am
participating.
I intend by this Waiver and Release to, in advance, waive, release and discharge all of the persons and entities mentioned in the preceding
paragraph from all claims for damages for death, personal injury or property damage that I or any minor with whom I am participating in the
event may have, or which may hereafter occur to me or any other person, as a result of my participation or any such minor’s participation in the
event, even though that liability may arise from negligence or carelessness on the part of the persons or entities being released or because of their
possible liability without fault. I understand and agree that this Waiver and Release is binding on the heirs, assigns and legal representatives of
me and any minor with whom I am participating in the event.
I am physically capable of participating in and completing this event, as is any minor with whom I am participating. If I or any such minor is
aware of or under treatment for any physical infirmity, ailment or illness, the appropriate medical care provider knows of and has approved my or
our participation in this event. I acknowledge that I, and I alone, am solely responsible for my own personal health and safety, and the personal
property I bring with me, as well as the personal health and safety, and the personal property, of any minor participating in the event with me. I
and any minor with whom I am participating in the event will abide by all rules and regulations established by the event organizers and personnel
as well as all local laws and ordinances. Further, I acknowledge that my or our participation in the event is subject to the sole discretion of, the
organizers and Medical Director and/or medical team of the event, and may be limited or halted for medical or other safety related reasons. To
the extent that I or any minor with whom I am participating in the event ride a bicycle, each rider shall wear a properly fitted and adjusted ASTM,
ASNI, CPSC or SNELL certified helmet while riding.
I understand that the name, photograph, voice or likeness of me or any minor with whom I am participating in the event may be used for any and
all promotional purposes related to the event. I consent to and authorize, in advance, such use and waive all rights of privacy and potential
financial benefit or compensation that I or any minor with whom I am participating in the event may have in connection therewith.
I have carefully read this Waiver and Release and fully understand its contents. I am aware that this is a release of liability and a contract between
myself and the persons and entities mentioned, and I enter into it of my own free will for myself as well as on behalf of any minor with whom I
am participating in the event.
SIGNATURE:
__________________________________________
Print Name
__________________________________________
Signature
__________________________
Date
Emergency Contact/Relation
Emergency Contact Phone #