panacafitnesscenter

Name__________________________________

Address________________________________

              _________________________________

E-mail:_________________________________

Phone:_________________________________

Sex     ______Male   ______Female

Age   ______          

 Shirt size:   ___Small  ____Medium   ___Large

                    ___X Large    ____XX Large

     [shirts may not be available for all events]

Entry Fee: _____Individual

[check with Dr. Klomp's office for couple/family/team discounts]

EVENT:        [Check one]

• _____April Fool 5&10K [$17.00]
• _____Kershaw-Ryan Run[$10 ]
• _____Condor Classic  [$20.00]
• _____Mini-Triathlon     [$25.00]
• _____The Country Mile[$22.00]
• _____Half Marathon     [$28.00]

                               Legal Waiver and Release

     I acknowledge that the _________________________________ is a dangerous event.  It is an extreme test of a person's physical and mental limits and carries with it the potential for death, serious injury, and property loss.  I understand that may will be other vehicles, including cars and trucks, along portions of the race route even though some portions of the route may be closed to some vehicles.  I agree to abide by all rules of the road at all times, whether or not portions are closed to some vehicles.  I further understand that serious accidents occasionally occur during these activities and that participants in these events can suffer serious injury or death.  NEVERTHELESS, I HEREBY ASSUME THESE RISKS OF PARTICIPATION IN THIS EVENT.  I certify that I am physically fit, have sufficiently trained for participation in this event, and have not been advised otherwise by qualified medical persons.  IN RETURN FOR PERMITTING ME TO PARTICIPATE IN THIS EVENT, I HEREBY WAIVE, RELEASE AND DISCHARGE ANY AND ALL CLAIMS FOR DAMAGES FOR DEATH, PERSONAL INJURY, DISABILITY OR PROPERTY DAMAGE OF ANY KIND WHICH MAY HEREAFTER ACCRUE TO ME AS A RESULT OF MY PARTICIPATION IN THIS EVENT.  THIS RELEASE IS EXPRESSLY INTENDED TO DISCHARGE IN ADVANCE THE PANACA FITNESS CENTER, LLC, IT'S EMPLOYEES, AGENTS, OR VOLUNTEERS OR CONTRIBUTORS OR SPONSORS FROM AND AGAINST ANY AND ALL LIABILITY ARISING OUT OF OR CONNECTED IN ANY WAY WITH MY PARTICIPATION IN THIS EVENT.  THIS RELEASE WILL APPLY EVEN THOUGH LIABILITY MAY ARISE OUT OF NEGLIGENCE OR CARELESSNESS ON THE PART OF THOSE DISCHARGED INCLUDING THEIR EMPLOYEES, AGENTS AND VOLUNTEERS.  I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS THE ENTITIES AND PERSONS HEREIN RELEASED FROM ANY AND ALL CLAIMS MADE BY OTHER INDIVIDUALS OR ENTITIES AS A RESULT OF ANY OF MY ACTIONS DURING MY PARTICIPATION IN THE EVENT AS WELL AS TRAVELING TO OR FROM THIS EVENT.  THIS WAIVER AND RELEASE SHALL APPLY TO ME AS WELL AS ANY OF MY HEIRS, EXECUTORS, ADMINISTRATORS, NEXT OF KIN, ASSIGNS AND SUCCESSORS. [EACH TEAM MEMBER (FOR RELAY TEAMS) MUST SIGN THIS WAIVER.]

  ___By my signature below, I hereby certify that I  am eighteen (18) years of age or order, that I have read this document, and that I understand it's contents.                                                                                                     

                                                                                                                     _________________________________________ date________

    The undersigned,___________________________________[name of parent or guardian] referred to as the parent or natural or legal guardian

 of: ________________________________________[Minor's name]  ____________[Minor's birthdate] does hereby represent that he or she is, in

fact, acting in such capacity and AGREES TO SAVE AND HOLD HARMLESS AND INDEMNIFY EACH AND ALL OF THE PARTIES HEREIN NAMED ABOVE AND RELEASE THEM AND THEIR EMPLOYEES, AGENTS, AND VOLUNTEERS FROM ALL LIABILITY, LOSS, OR HARM THAT MAY OCCUR BY REASON OF THE MINOR'S PARTICIPATION IN THE ABOVE-DESCRIBED EVENT.  BY THE SIGNATURE BELOW, THIS PARENT/GUARDIAN ACKNOWLEDGES AND AGREES TO THE ABOVE AS WELL AS THIS WAIVER AND RELEASE.  FURTHER, ANY DEFECTS OR LACK OF CAPACITY TO SO ACT, WAIVE, AND RELEASE ANY RIGHTS ON BEHALF OF BOTH THE MINOR AND THE PARENT/GUARDIAN IS HEREBY WAIVED.  ADDITIONALLY, THE PARENT/GUARDIAN AGREES TO PERSONALLY SUPERVISE THE MINOR BEFORE, DURING, AND AFTER THIS EVENT.

   ________________________________________                                                                                                     ________________________________________       Date ______________

                 Signature of Parent/Guardian            

 Relationship to Minor  _______________________________     Date ___________