Docstoc

SPONSORSHIP FORM

Document Sample
SPONSORSHIP FORM Powered By Docstoc
					      Southeastern Cancer Care
      Cures for the Colors – Marathon/100 Mile
              Ultra-Marathon Walk/Run
     Saturday, April 21, 2012 – Start Time 9:00 a.m. – 30 hour cut-off
                                          Liability Waiver Form

     Acknowledgement, waiver and release from liability (WRL) I acknowledge that a Marathon and a
     100-mile walk/run ultra- marathon is an extreme test of a person’s physical and mental limits and
     carries with it the potential for death, serious injury, and property loss. I HEREBY ASSUME THE
     RISKS OF PARTICIPATION IN MARATHON OR 100-MILE WALK/RUN MARATHON.
     I certify that I am physically fit, have sufficiently trained for participating in this event(s), and have
     not been advised otherwise by a qualified medical person.

     I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and
     assigns as follows: 1) WAIVE, RELEASE, DISCHARGE AND AGREE NOT TO SUE, from any
     and all liability for my death, disability, personal injury, property damage, property theft or action of
     any kind which may hereafter occur to me as a result of my participation in, or my travelling to or
     from this event THE FOLLOWING PERSONS OR ENTITIES: event sponsors, race directors,
     event producers, event volunteers and al cities, counties, districts and/or states in which said events
     may be stages or in which segments of said events may be run and its (their) officers, directors,
     employees, representatives and agents and volunteers; 2) INDEMNIFY AND HOLD HARMLESS
     the persons or entitles mentioned in this paragraph from any and all liabilities or claims made by
     other individuals or entities as a result of any of my actions during the Southeastern Cancer Care
     MARATHON or 100 MILE WALK/RUN ULTRA MARATHON.

     I hereby consent to receive treatment in the event of my injury, accident and/or illness during this
     event. I understand that I may be photographed. I agree to allowing my photo, video or film likeness
     to be used for any legitimate purpose by the event producer(s), event sponsors(s) and or assigns.




________________________________                      ________________________________
Signature                                             Print Name

_________________________________                     ________________________________
Parent’s Signature (If under age 18)                  Parent’s Print Name

___________________
Date

                Please sign and fax to “Event Organizer” at 919-580-0209 prior to 04/20/2012.
                     Southeastern Cancer Care
         Cures for the Colors – Marathon/100 Mile
                 Ultra-Marathon Walk/Run
     Saturday, April 21, 2012 – Start Time 9:00 a.m. – 30 hour cut-off
          The course will be a 5.26 mile loop starting across the street from Wayne Memorial Hospital.
          Nourishment/first aid will along the route.

         Individuals or teams of 20 or less can participate. Medals will be given to all participants. Awards will
         be given to the teams that raise the most, fastest times (individuals and teams). All proceeds will be
         used to assist cancer patients and their families in Eastern NC. Each participant will receive a packet
         with a t-shirt, safety arm band and other goodies.



         To register for the Cures for the Colors Marathon/100
                               Mile Ultra
         Visit www.southeasternncancercare.org or email 100miles@southeasterncancercare.org Include
         name, age, phone number, email address and t-shirt size in your email. Registration fees: $60.00
         individual OR $30.00 PER PERSON for teams. Please remember that this is a fund raiser and all
         participants are encouraged to get per mile sponsors. Other questions call 919-580-000.

         Individual Entrants $60 Registration Fee
Individual Entrant Name                                                                    Age       T-Shirt Size


Phone:                         Email:



         Teams: $30 PER Member Registration Fee – Copy this sheet for teams of 11 or more members.
Team Name:


Captain Name                                                                               Age       T-Shirt Size


Phone:                         Email:

Name 2                                                                                     Age       T-Shirt Size


Name 3                                                                                     Age       T-Shirt Size


Name 4                                                                                     Age       T-Shirt Size


Name 5                                                                                     Age       T-Shirt Size


Name 6                                                                                     Age       T-Shirt Size


Name 7                                                                                     Age       T-Shirt Size


Name 8                                                                                     Age       T-Shirt Size
Name 9                                                                                             Age       T-Shirt Size


Name 10                                                                                            Age       T-Shirt Size




          Southeastern Cancer Care
          Cures for the Colors – Marathon/100 Mile
                         Walk/Run
Team/Individual Name               ________________________________________________________________
                                                                                      Per Mile      Flat            Paid Amount
                                                                                      Sponsored     Sponsored
Name/Phone                        Email Address
                                                                                      Amt           Amount




Make checks payable to Southeastern Cancer Care.
All proceeds will benefit the cancer patients and their families of Eastern North Carolina and should be sent to:

                                 Southeastern Cancer Care
                                 203 Cox Boulevard
                                 Goldsboro, NC 27534 – Or fax to 919-580-0209

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:6
posted:12/8/2011
language:
pages:3