5K Run/Walk 2011 - October 8


Below is the online registration form for easier use. You can download the print form here. Once you fill out the necessary information, you will be sent to the payment page.

Name (Team)
Address
Address 2
City
State
Zip
Phone Cell Number
Email
T-Shirt Size
Breast Cancer Survivor
Duty Performing
   
 

Emergency Contact

Name
Relationship
Phone
Cell Number
Email
 
 

In consideration of the County of Dekalb and Sisters of Faith Organization permitting me and/or my minor child/ward to participate in the Glenda J. Black 5K Breast Cancer Run/Walk event, and to engage in all activities related to the event, the Undersigned Participant/Parent/Guardian and/or Minor Child/Ward, for himself/herself and personal representatives, assigns, heirs and next of kin, or any of them: 1) Hereby releases, waives, discharges and covenants not to sue the County of Dekalb, Sisters Of Faith, Beulah Missionary Baptist Church, or The Gallery at South DeKalb Mall, its officers, employees, agents, for all purposes herein referred to as Releasees, from all liability to the Undersigned Participant/Parent/Guardian and/or Minor Child/Ward, his/her personal representatives, assigns, heirs and next of kin for all losses or damage and any claim or demands therefore, on account of injury to the person or property or resulting in death of the Undersigned Participant/Parent/Guardian and/or Minor Child/Ward, whether caused by the negligence of Releasees or otherwise while Undersigned Student is participating in the Glenda J. Black 5K Breast Cancer Run/Walk event. 2) Hereby agrees to indemnify and save and hold harmless the Releasees and each of them from any and all losses, liabilities, damages, costs, actions, claims or demands of any kind and nature whatsoever which may arise by on in connection with Undersigned Participant/Parent/Guardian and/or Minor Child/Ward?s participation in the aforementioned event, whether caused by the negligence of the Releasees or otherwise. The Undersigned Participant/Parent/Guardian and/or Minor Child/Ward is fully aware of the risks and hazards inherent in the aforementioned event and hereby voluntarily elects to participate in said the aforementioned event with knowledge of any danger involved. The Undersigned Participant/Parent/Guardian and/or Minor Child/Ward hereby voluntarily assumes all risk of loss, damage, injury, or death that may be sustained by the Undersigned Participant/Parent/Guardian and/or Minor Child/Ward while participating in the aforementioned event. The Undersigned Participant/Parent/Guardian and/or Minor Child/Ward expressly agrees that the foregoing Release, Waiver and Indemnity Agreement is intended to be as broad and inclusive as is permitted by law of the State of Georgia and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

THE UNDERSIGNED PARTICIPANT/PARENT/GUARDIAN AND/OR MINOR CHILD/WARD HAS CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTANDS ITS CONTENTS. THE UNDERSIGNED PARTICIPANT/PARENT/GUARDIAN AND/OR MINOR CHILD/WARD IS AWARE THAT THIS IS A RELEASE OF LIABILITY AGAINST THE RELEASES AND SIGNES IT OF HIS/HER OWN FREE WILL.

I agree to the terms (check box)        

Mailing Options

After filling out the form, you will be taken to the payment page. If you do not wish to make a payment online, you can send a check or money order for ($25 - Adult (per person); $15 for Senior (60+) or Youth (7-13) to:

Sisters of Faith
4919 Flat shoals Pkwy Suite 107B-114
Decauter Georgia 30034
678-278-9636
Toll Free: 888-610-2246

Full Name


Phone (Optional)


Email


Comments



 

 

Site Design by Seven Creative Media Group