Address:

                          City:

                        State:

                            Zip:

                       Phone:

                     E-Mail:

  Age On Race Day:

                    Gender:   Select One Female Male

             T-Shirt Size:   Select One Small Medium Large Extra Large

Waiver of Participation

ADULT AUTHORIZATION FOR EMERGENCY & ROUTINE MEDICAL TREATMENT AND RELEASE OF LIABILITY, I give my permission to Meridian Plumbing, it’s volunteers, employees, and representatives, to obtain or provide such emergency or routine medical treatment for me as they, in the exercise of their discretion, deem necessary or appropriate while I participate in any activity offered by Meridian Plumbing. Further, in consideration of Meridian Plumbing making this available to me, I, for myself, and anyone claiming under or through me, hereby release and discharge Meridian Plumbing, its employees, representatives and volunteers from all liability, claims, demands, and actions,

ADULT CONSENT TO PHOTOGRAPH/VIDEOTAPE & DISSEMINATE WITHOUT COMPENSATION, I hereby consent to being photographed/videotaped while participating in any activity offered by Meridian Plumbing. In addition, I consent to the reproduction and use of any such photographs and videotapes by Meridian Plumbing for educational, public relations and promotional purposes and I waive any claim by myself, or anyone claiming under or through me, for compensation of any kind in exchange for photographs, videotapes and use.

    Agree To Waiver:   Select Yes

                 Signature:              

Signature above must be signed by parent or guardian if under 18