1999 Coastal Corporation
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Name___________________________________________________________________________ |
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| [ ] My $15 entry fee is enclosed. (on or before May
15) [ ] My $20 late entry fee is enclosed (May 16-22) [ ] Check this box for reservations to return by bus at 1:30 p.m. How did you hear about the ride?______________________________________________________ Credit Card (circle) .......Visa........ MasterCard....... American Express.....Expiration Date_____________ Credit Card #_______________________________________________________________________ |
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LIABILITY RELEASE FORM |
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| I,
_______________________________, intending to be legally
bound, understand and agree that I am voluntarily
participating in the following Leukemia Society of
America, Inc. event, The Coastal Corporation 100K Classic
at my own request and at my own risk. I acknowledge that
I am aware of all the risks inherent in this event and
certify that I am physically fit, have not been otherwise
informed by any physician and know of no restriction
imposed 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, on behalf of myself, my successors in interest, heirs, assigns and representatives, hereby fully release and agree to hold harmless the Leukemia Society of America, Inc. and its representatives, successors and entities (be they individuals or organizations, singly and collectively) (Society), together with their insurers, of and from any and all liability, claims, damages or causes of action for any reason, including, without limiting the generality of the following, death, bodily injury, property damage or any other loss or inconvenience whatsoever, suffered by participation in this event (liabilities). I also give permission for the free use of my name, picture and voice in any broadcast, telecast, print account or any other account in any medium of this event. Participant
Signature_______________________________
Date:______________________________ The undersigned certifies that
he/she is the parent or legal guardian of the participant
, and as such and on behalf of myself and the
participant, agrees to the terms of this release,
releases all parties and entities set forth above from
all liabilities, and indemnifies and holds harmless the
Society from all liabilities. |
| General Information | Ride Information | Registration Form | Sponsor Form |
| HPD Bike Relay Team | Houston, Texas Links | Leukemia Society | Hand drawn ride map |
| For
More Information: Mark L. Curran, Captain Chair - HPD Bike Relay Team (713) 928-4600 |
For
LSA Information: Joan Jarrett, Executive Director LSA - Texas Gulf Coast Chapter 10777 NW Freeway, Suite 600 Houston, TX 77092 (713) 680-8088 Fax #: (713) 683-9504 |
To Congratulate the |
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