Excelsior Charter School CTE Academy’s 5K Anti-Bullying Color Run ENTRY FORM Name_________________________________________________________________________ Street Address__________________________________________________________________ City___________________________________________________________________________ Age as of April 25th 2015__________________________________________________________ Circle Shirt Size: S M L XL 2XL 3XL Make Checks Payable to: Excelsior Barstow ASB Mail Registration to: Excelsior Charter School CTE Academy 1497 State St. Barstow, CA 92311 Help raise awareness of the dangers of bullying and promote bullying prevention. **This is a fundraiser for Excelsior CTE Academy’s ASB. 10% of proceeds will be donated to bullying prevention** RELEASE OF LIABILITY I know that running/walking in a road race is a potentially hazardous activity. I represent that I am medically able and properly trained to participate in this event. I assume all risks associated with this event including, but not limited to, heat exhaustion, falls, contact with other participants, effects of weather, dangerous traffic conditions, etc, all such risks being known and recognized by me. I hereby agree, for myself and my heirs, assigns, personal representative, executors and administrators, to waive, release, and forever discharge Excelsior Charter School and its respective directors, officers and employees, volunteer, and any and all sponsors, suppliers and any other personnel assisting or connected with this event, any rights claims, or demands therefore which I may have or which I may hereafter accrue to me arising out of injury to my person or my property incurred in connection with participation in the Excelsior Charter School CTE Academy 5K Color Walk/Run held on April 25th, 2015 ______________________________________________________________________________ Signature Date ______________________________________________________________________________ Parent’s Signature (if under 18 years of age) Date