Waiver of liability for zumba classes at hickory hills
Sign up Sheet for Leon\'s Walk/Run
1. Leon Deraps 5 mile Memorial Run/Walk/Ride
Sign Up
Participant Information
Name: _____________________________________
Address: ___________________________________
City, State, Zip:
______________________________
T-Shirt Size:
_________________________________
Participation Waiver:
In signing this release, I acknowledge that I understand the intent thereof and I hereby release,
absolve, and hold harmless the Leon Deraps Scholarship Fund or any other parties connected
with this event in any way, singly of collectively from and against blame and liability for any
death, injury, misadventure, harm, loss, inconvenience or damage hereby suffered or sustained
as a result of my participation in the 2010 Leon Deraps Memorial Scholarship Run/Walk/Ride
Event or any activities associated therewith. I hereby consent to and permit emergency
treatment in the event of illness or injury. I also, give full permission for use of my name
and/or photo in connection of this event.
If signed by a parent, the parent agrees to release and hold the above name organization and
persons harmless of any claims, which may be asserted by or on behalf of the entrant.
Signature of participant:________________________________________________
Signature of guardian if under 18: ________________________________________
2. Date: ______________________________________________________________
Participation Waiver:
In signing this release, I acknowledge that I understand the intent thereof and I hereby release,
absolve, and hold harmless the Leon Deraps Scholarship Fund or any other parties connected
with this event in any way, singly of collectively from and against blame and liability for any
death, injury, misadventure, harm, loss, inconvenience or damage hereby suffered or sustained
as a result of my participation in the 2010 Leon Deraps Memorial Scholarship Run/Walk/Ride
Event or any activities associated therewith. I hereby consent to and permit emergency
treatment in the event of illness or injury. I also, give full permission for us of my name and/or
photo in connection of this event.
If signed by a parent, the parent agrees to release and hold the above name organization and
persons harmless of any claims, which may be asserted by or on behalf of the entrant.
Signature of participant:________________________________________________
Signature of guardian if under 18: ________________________________________
Date: ______________________________________________________________
Participation Waiver:
In signing this release, I acknowledge that I understand the intent thereof and I hereby release,
absolve, and hold harmless the Leon Deraps Scholarship Fund or any other parties connected
with this event in any way, singly of collectively from and against blame and liability for any
death, injury, misadventure, harm, loss, inconvenience or damage hereby suffered or sustained
as a result of my participation in the 2009 Leon Deraps Memorial Scholarship Run/Walk/Ride
Event or any activities associated therewith. I hereby consent to and permit emergency
treatment in the event of illness or injury. I also, give full permission for use of my name
and/or photo in connection of this event.
If signed by a parent, the parent agrees to release and hold the above name organization and
persons harmless of any claims, which may be asserted by or on behalf of the entrant.
Signature of participant:________________________________________________
Signature of guardian if under 18: ________________________________________
