Pelican Fire & Rescue
4093 County P
Rhinelander, WI 54501
Hodag Painted Run – August 1, 2015
Name: ____________________________________________________________________
Address:__________________________________________________________________
City:________________________________State:_____________Zip:________________
Email Address:____________________________________________________________
Phone #(s) ( ) ( ) _______
Date Of Birth:______________ Age On Race Date Above:_____Sex: (Circle) M F
Emergency Contact Name:___________________ Phone # ( ) _
Shirt Size Unisex(Circle): Small, Medium, Large, Extra Large.
Entry Fees – Please Choose event (Circle): 10K ($) 5K ($)
Entry Fee (No refunds, No transfers): ………………….…………$_______________
Total Amount closed:………………………………………………$_______________
ACCIDENT WAIVER AND RELEASE OF LIABILITY:
In consideration of acceptance of my application in the above runs on , I hereby waive, release and discharge any and all claims on behalf of myself, my heirs, assignee, and/or estate for damages, death, personal injury or property damage as a result of my participation in, including traveling to this event. I understand that this release is to discharge in advance the Marathon organizers, , private property owners, race sponsors, medical personnel, local jurisdictions and their employees, and race volunteers (the “Releases”) including any and all rights, claims and liability for damage or injuries to me or my property caused by negligence of any of them, arising out of my participation in this footrace, together with any costs, including attorney’s fees, that may be incurred as a result of such claims, whether valid or not; and expressly waive any benefit I may otherwise have. I hereby acknowledge that participation in this race carries with it potential hazard and risk which I voluntarily assume, and therefore release all Releasees of responsibility for my injury or death during this race. I hereby attest and verify that I am physically fit and have sufficiently trained for this arduous event. I hereby accept full responsibility and knowledge for following the correct course. I hereby state I will voluntarily withdraw from this race if requested to do so by race management or course volunteers. I hereby consent to receive medical treatment at my cost, which race officials may deem necessary in the event of injury, accident or illness during the footrace. I have also been advised that I may be exposed to physical injury from a number of natural factors, including, but not limited to lack of water, too much water, the hazards of vehicular traffic, and those other hazards attendant to running or walking along or across busy roadways during the day or night, including, among other things, the fact that I may become injured or incapacitated in a location where it is difficult or impossible for the event management to get required medical aid to me in time to avoid physical injury or even death. I understand that entry fees are necessary to meet the costs of preparations months in advance of the race, and if the race is cancelled because of fire, drought, floods, storms of any kind, known or known, I expressly waive any benefit I may otherwise have.
Signature: _______________________________ Date: _______________________________
Parental Signature for Under 18 Yrs old.
Signature: _______________________________ Date: _______________________________
