Your full name:
Relationship to the child being registered:
First Name of child:
Last Name of child:
Middle Initial (option):
Age on 8/1/09:
Year of Birth:
Street Address:
City/Town:
State:
Zip Code:
Gender M or F:
Telephone:
T-Shirt(Children's Sizes):
Email Address:
WAIVER - I know that physical activity
is a potentially hazardous activities and that my children should not
enter and run unless they are medically able. I waive and release the
Gate City Striders, the Southern NH Medical Center and any and all other
individuals and organizations assisting at the event on race day, and
all sponsors and their representatives and successors from all claims
of liabilities of any kind arising out of my participation or my children's
participation in this event.
I grant permission to Fitness University
and/or the Gate City Striders and/or its sponsors to use any photographs,
motion pictures, recordings, or any other record of this event for any
legitimate purpose.
I hereby give permission to the medical
personnel selected by Fitness University and/or Gate City Striders, including
without limitation, coaches, volunteers and staff to provide transportation
and all necessary medical and dental care for the above-named child.
I hereby give permission to the medical
care provider(s) selected by Fitness University and/or Gate City Striders
to secure and administer all necessary treatment, including hospitalization
, for the child. This care may be given under whatever conditions are
necessary to preserve the life, limb, or well-being of the child.