INDVIDUAL PARTICIPANT
TEAM LM REGIRATRTION, LIABILITY, AND WAIVER FORM
LAST NAME / FIRST NAME / MIDDLE INITIAL / D.0.B.STREET ADDRESS/PO BOX / CITY / ZIP CODE / HOME PHONE
EMAIL ADDRESS / EMPLOYER / WORK PHONE / CELL PHONE
EMERGENCY CONTACT / RELATIONSHIP / HOME PHONE / CELL PHONE
I understand and agree that I am voluntarily participating in the Liam’s Land Organization TEAM LM event by my own request, and at my own risk. I acknowledged that I am aware of all the risk inherent in this event. I certify that I am physically fit and have not been otherwise informed by any physician and know of no restrictions on me by my own physician that would in any way prevent me from actively participating in this event.
In consideration of being permitted to participate in this event, I oh behalf of myself, my successors in interest, heirs, and representatives, hereby fully release and agree to hold harmless the Liam’s Land Organization, Inc., its officers, trustees, agents, employees, and representatives, successors, and entities of and from any and all liability, claims, damages, and causes of action for any reason including loss, or inconvenience whatsoever, suffered by me at any time hereafter occurring as a result of my voluntary participation in this event. I also give permission for the free use of my name, picture, and voice broadcast, telecast, print account, or any other account in any medium of this event.
___ (initial) I am over 18 years of age ____ (initial) Participant is under 18 years of age
I want to participate in the following event: ___ Savannah Rock n Roll Half/Full marathon
___ Oregon Wine Country Half Marathon Weekend
___ Other ______
Printed Participant Signature/Legal guardian: ______Date: ______
Signature: ______
*All Team LM participants will receive a training shirt, per donation outlined in information packet
TEAM LM shirt size: SMLXL