Shelby County Polar Bear Triathlon Registration

Name(last)_____________________________  (first)_____________________________

Age on Race Day_______ Birthday_______________________ Sex_________

Address_____________________________________________________________

City____________________________ State________________ Zip ______________

Phone (       )_________________________________

Entry Fee: (circle one)    $30 before Jan 29th                $40 after Jan 29th

Signature (parent or guardian if under 18)_________________________________ Date______________

In consideration of the acceptance of my entry in the

Shelby County Polar Bear Triathlon

1.    I hereby agree to comply with all the rules and regulations and event instructions of the Shelby Co. Polar Bear Triathlon and its directors.

2.    For myself, my executors, administrators, heirs, next of kin, successors and assigns, I Hereby: (a) waive and release any and all claims that I may have against the Polar Bear Triathlon, its Event committee, their officers, directors, members, volunteers, employees, sponsors, or anyone or more of them, their executors, adminisrators, heirs, next of kin, successors or assigns ("their releases") including any and all claims for damage caused by the negligence of any of them, arising out of my participation in the event and its related activities, together with any costs, including attorney's fees that may be incurred as a result of any such claim whether valid or not, and (b) indemnify and hold harmless the releases and each of them against any such claim that I or my guests or anyone or more of my or their executors, administrators, heirs, next of kin, successors or assigns may have or assert and against any cost including attorney's fees with respect thereto..

3.    I hereby acknowledge that I have sole responsibility for my personal possesions and athletic equipment during the Polar Bear Triathlon event and its related activities.

4.    I hereby acknowledge that perticipation in the Polar Bear Triathlon competition carries with its potential hazards.  I therefore release the Polar Bear Triathlon, its event committee, their officers, directors, members, volunteers, employees, or sponsors of any liability resulting from injury or death during the event and its related activities.

5.    I hereby attest and verify that I am physically fit and have sufficiently trained for this competition and that my physical condition has been verified by a licensed medical doctor.

6.    I hereby consent to receive medical treatment which may be deemed adviable in the event of injury, accident and/or illness during the Polar Bear Traithlon Event.

7.    I hereby agree that in the event of race cancellation due to storm, rain, inclement seas, or weather, winds or other "Acts of God" conditions, my enrollment fee shall be non-refundable.

Signature(Parent or Guardian if under 18)____________________________________ Date_______________

Make check payable to Headfirst Performance Services and Mail to:

7024 Buckcreek Rd., Finchville, KY 40022

Must be postmarked by January 29 for early registration fee.

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