First Name:

                 Address:

                        City:

                      State:

                          Zip:

                     Phone:

                      Email:

                   Gender:   Select Female Male

Age On Event Day:

                Shirt Size:   Select Adult Small Adult Medium Adult Large Adult XL Youth Small Youth Medium Youth Large Youth XL

      SVTC Discount:Check this box if you are a Shenandoah Valley Track Club Member

                      Event:   Select 1 Mile Run 5K Walk 5K Run

Race Waiver I, for myself or as parent or guardian, here by assume all of the risks and hazards incidental to the conduct of the activities. I release, absolve, and indemnify the town of Bridgewater, Shenandoah Valley Track Club, and Kaleidoscope Child & Family Services, Inc. employees of the town, volunteers, contractors, and/or sponsors from all the risks and hazards associated with the activities and in the event of injury, do expressly waive all claims against them. I understand that no insurance coverage is provided. I further give permission for proper emergency care to be rendered to myself or child should I not be available or able to give such permission. As part of this approval, I acknowledge I may have the opportunity to review the premises, equipment and personal qualifications to be used in conducting the activity. I also have the opportunity to discuss with program organizers potential hazards and risk that may be associated with the activity and take responsibility for doing so. Failure

                   Waiver:   Select Yes

Electronic Signature:        Parent Or Guardian Must Sign If Under 18

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