HEART & SOLE TRIATHLON REGISTRATION (entries non-transferable)
Please complete both pages fully and neatly be sure to sign the waiver
Make Checks Payable to VWCPRD
Mail to: Headfirst Performance Services, 7024 Buckcreek Rd, Finchville, KY 40022
Name:(last)______________________(first)___________________Sex________
Address:____________________________________Date of Birth____________
City:__________________State:______Zip__________
Phone:______________________Email______________________________
USAT#_____________________________
Physically Challenged?________ Shirt size (circle one) S M L XL
Entry Fee: (Circle one) Before April 3: USAT Member $45 Non Member $55
After April 3: USAT Member $55 Non Member $65
Estimated 400 Yard Swim time (please be as accurate as possible)
Less than 6 min Less than 8 Less than 10 Less than 12 Less than 14 Over 14
Waiver- Release and Indemnification
In consideration of the acceptance of my entry in the "Heart & Sole Tri/ Du" (Hereafter refered to as the event):
1. I hereby agree to comply with all the rules, regulations and event instructions of the event and its directors.
2. (a) For myself, my executors, administrators, heirs, next of kin, successors and assigns, I HEREBY:
wave and release any and all claims that I may have against the event, its Event Committee, their officers, directors, members, volunteers, employees, sponsors, or any one or more of their executors, administrators, heirs, next of kin, successors or assigns (their releases) including any and all claims for damage caused by the event and its related activities, together with any cost, including attorney's fees, that may be incurred as a result of any such claim whether valid or not, and (b) indemnify and hold harmless the releases and each of them against any such claims that I or my guest of any one or more of their executors, heirs, next of kin, successors, or assigns may have or assert and against any cost including attorney's fees with respect thereto.
3. I hereby acknowledge that I have sole responsibility for my personal possesions and athletic equipment during the event and its related activities.
4. I hereby acknowledge that participation in the event carries potential hazards. I therefore release the event its event committee, their officers, directors, members, volunteers, employees and sponsors of any liability resulting in injury or death during the event or its related activities.
5. I hereby attest and verify that I am physically fit and have sufficiently trained for this competition and that my physical condition has been verified by a licensed medical doctor.
6. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and/ or illness during the event.
7. I hereby agree that in teh event of race cancellation due to storm, rain, inclement seas or weather, winds or other "Acts of God" conditions, my enrollment fee shall be non refundable.
Signature (Parent or Guardian if under 18) ____________________________________
Date__________________