2009 GRANITEMAN TRIATHLON REGISTRAION FORM

NORTH CREST GYMNASTICS & DANCE

ATTENTION: GRANITEMAN TRIATHLON

1009 INDUSTRIAL DR SOUTH

SAUK RAPIDS, MN 56379

Last Name: First Name:

Phone Number: Email:

City: State: Zip:

Emergency Contact: Emergency Phone Number:

Address:

Age Race Day: Date of Birth: Gender :

T-shirt Size ( M / L / XL / XXL )

Divisions:

Individual / Relay Co-ed / Relay Male / Relay Female

Relay Team Name:

Swimmer: Biker: Runner:

Each team member must submit an entry form. Please send all entry forms together.

Fee Schedule Postmarked by:

Before March 1 - Individual $45 Relay $60

Before May 31 - Individual $55 Relay $70

Before June 29 - Individual $65 Relay $80

Total Enclosed _________

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ACCIDENT WAIVER AND RELEASE OF LIABILITY

I acknowledge that the Graniteman Triathlon 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, and event monitors, and/or producers of the event, and lack of hydration. I hereby assume all the risks of participating in this event. I certify that I am physically fit, have sufficiently trained for participation in the Graniteman Triathlon, 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 the responsibilities at said event. In consideration of my application and permitting me to participate in the Graniteman Triathlon, 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 or my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSON: North Crest Gymnastics and Dance, City of Rockville, Stearns County, MN DNR , Pickle Events LCC, their directors, officers, employees, volunteers, representatives, and agents, the event holders, event sponsors, event directors, event volunteers; (B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made by other individuals or entities as a result of my actions during the Graniteman Triathlon. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during the event. I understand that at this event 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, sponsors, organizers and/or assigns. This AWRL shall be construed broadly to provide release and waiver to the maximum extent permissible under applicable law: I hereby certify that I have read this document; and, I understand its content.

Signature_____________________________________________________________________________