Excelsior Charter School CTE Academy`s 5K Anti

Excelsior Charter School CTE Academy’s 5K Anti-Bullying Color Run
ENTRY FORM
Name_________________________________________________________________________
Street Address__________________________________________________________________
City___________________________________________________________________________
Age as of April 25th 2015__________________________________________________________
Circle Shirt Size:
S
M
L
XL
2XL
3XL
Make Checks Payable to:
Excelsior Barstow ASB
Mail Registration to:
Excelsior Charter School CTE Academy
1497 State St. Barstow, CA 92311
Help raise awareness of the dangers of bullying and promote bullying prevention.
**This is a fundraiser for Excelsior CTE Academy’s ASB. 10% of proceeds will be donated to
bullying prevention**
RELEASE OF LIABILITY
I know that running/walking in a road race is a potentially hazardous activity. I represent that I
am medically able and properly trained to participate in this event. I assume all risks associated
with this event including, but not limited to, heat exhaustion, falls, contact with other
participants, effects of weather, dangerous traffic conditions, etc, all such risks being known
and recognized by me. I hereby agree, for myself and my heirs, assigns, personal
representative, executors and administrators, to waive, release, and forever discharge Excelsior
Charter School and its respective directors, officers and employees, volunteer, and any and all
sponsors, suppliers and any other personnel assisting or connected with this event, any rights
claims, or demands therefore which I may have or which I may hereafter accrue to me arising
out of injury to my person or my property incurred in connection with participation in the
Excelsior Charter School CTE Academy 5K Color Walk/Run held on April 25th, 2015
______________________________________________________________________________
Signature
Date
______________________________________________________________________________
Parent’s Signature (if under 18 years of age)
Date
`