25K registration is closed
no entries postmarked after 3/14/13 will be taken
ACCIDENT WAIVER & RELEASE OF LIABILITY
RACE REGISTRATION FORM
This form must be read carefully, filled out completely and signed by each runner.
Haulin' in the Holler 5k/25k/50k Trail Run
NAME: __________________________ AGE (on day of race): ________
DOB: _______________ SEX: ____________ Active Military(y or n): ______
Veteran(y or n):__________
PO BOX OR STREET: _____________________________________
CITY: _______________________________ STATE: __________
E-MAIL ADDRESS: ____________________________________
EMERGENCY CONTACT: _______________________________
Application fee 50K: $50 if postmarked by Feb 23 and $60 until Mar 16______
25K registration is closed_
5K: $20 if postmarked by Feb 23 and $25 until Mar 23______
Kids Fun Run: $5 ______
Total Amount Enclosed __________
25K/50K Shirt Size (circle one) Men: S M L XL Women: XS S M L XL
5K Shirt Size (circle one): S M L XL
Kids Fun Run Shirt Size (circle one) Child: S M L XL
No entries taken after Mar 16, 2013, except for 5K and Kids Fun Run
Checks or money orders should be made out to WVMTR and mailed to:
1371 Bills Creek Rd
Winfield, WV 25213
" I acknowledge that this athletic event 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. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of athletes, equipment, vehicular traffic, actions of other people including but not limited to, participants, volunteers, spectators, coaches, event officials, event monitors, producers of the event and lack of hydration. These risks are not only inherent to athletics, but are also present for volunteers. I hereby agree to assume all of the risks of participating and/or volunteering in this event. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective property owned, maintained or controlled by them or because of their liability without fault.
" I certify that I am physically fit, have trained sufficiently for participating in this event and have not been advised otherwise by a qualified medical person.
" I acknowledge that this Accident Waiver and Release of Liability (AWRL) form will be used by the event holders, sponsors and organizers, in which I may participate and that it will govern my actions and responsibilities at said events.
" In consideration of my application and permitting me to participate in this event, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) Waive, Release and Discharge from any and all liability for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to me including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: BSA Troop 164, Putnam County Parks and Recreation, Corey Family and The West Virginia Trail Runners, affiliated organizations and any involved municipalities, their directors, officers, employees, volunteers, representatives or agents, the event holders, event directors, event sponsors, event volunteers, property owners: (B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this event, whether caused by the negligence of releases or otherwise.
" I hereby consent to receive medical treatment, which may be deemed advisable in the event of injury, accident and/or illness during this event.
" I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, organizers and/or assigns.
" This Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum permissible under applicable law.
" I further agree to abide by all the rules and regulations as set forth by the director of this event.
" I hereby certify that I have read this document and I understand its contents.
Entrants Signature:__________________________ Date: ___________
(Note: If entrant is age 17 or under, Signature of Parent or Guardian is required below) The undersigned parent and natural guardian or legal guardian does hereby represent that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, claim or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.
Signature of Parent or Guardian: ___________________________________ Date: ________________________