ELKS FUN RUN FOR VETERANS * SEPTEMBER 12, 2009

RIDER # _____________ (Will be assigned by Office)

NAME: _________________________________________ DOB ________________

ADDRESS: __________________________________________________________

CITY: _________________________ STATE: ______________ ZIP: ____________

PHONE: ____________________ E MAIL: _____________________# RIDERS____

VEHICLE: ________________ LIC # _________________ WDL # ______________

RELEASE AND ASSUMPTION OF RISK

All participants must complete this form before receiving their scorecard

In signing this release, I acknowledge that I understand its intent, and for myself, my heirs, executors, administrators, and representatives do hereby agree and will absolve and hold harmless THE BENEVOLENT PROTECTIVE ORDER OF ELKS, WASHINGTON STATE ELKS ASSOCIATION, Individual Elks Lodges, American Lake Veterans Hospital, American Veterans, United States Department of Veterans Affairs, corporate sponsors, cooperating organizations and other parties connected with the event in any way, together with their respective successors and assignees (the sponsors), singly and collectively from and against blame and liability for any injury, harm, loss, inconvenience, or any damage of any kind, which may results from, or be connected in any way to my participation in the ELKS FUN RUN FOR VETERANS.

In addition to release from all liability, I hereby represent I am physically capable of participating in the event, that my vehicle and any other equipment I may use to participate in the event is in working condition, that I will observe all traffic and event rules and will conduct myself in a safe and prudent manner while participating in the event. I have my own liability insurance.  I hereby absolve and hold harmless the sponsors from any damage I may sustain because of breach of these representations.

I hereby consent to and permit emergency treatment in the event of injury or illness while participating in the event. I also give permission to the Elks to use my name and any photographs taken of me during the event in any promotional materials or publications.

I certify that I have read this waiver and understand its significance.

Participant’s Signature ____________________________________________ Date __________________

Signature of parent or legal guardian required below if participant is under 18.

Parent/Legal Guardian’s Signature __________________________________ Date ____________________