| Name | First | Last |
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| Address (Include Apt. No.) | ||
| City | ||
| State | Zip Code | |
| Telephone | ||
| I will be | |
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| (Please staple all family member registrations together and send with the fee.) | |
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Tank Top size (check one) |
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| Circle One: Master Card Visa | Amount $ __________________ |
| Number: ________-________-________-________ | Expiration Date: _________/_________ |
In consideration of the foregoing, I for myself,
my executors, administrators, and assignees do hereby release and discharge St.
Nicholas Hospital, the City of Sheboygan, Sheboygan Police Department, the
Sheboygan County YMCA, and all other entities and individuals who are in
any way connected with the event from any liability or claims for damages,
injury, or illness arising or growing out of my participation in the St.
Nicholas Hospital Freedom Run. I
represent that I have adequately trained and am medically able to participate in
this event, recognize the risks of injury that accompany such participation, and
acknowledge that this release is being relied upon by St. Nicholas Hospital in
permitting me to participate. I grant full permission without compensation to
St. Nicholas Hospital to use any photographs, recordings, or other reproductions
of me participating in this event.
Entrant's Signature |
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| (If
minor - parent or guardian's signature) |
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MAKE CHECKS PAYABLE TO |
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| Print and complete entry form and return to: | ||
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Communication Education |
OR | YMCA 812 Broughton Drive P.O. Box 609 Sheboygan, WI 53082-0609 |