MISSION
Entry Form 2012
Entry
Fees
- Registration Closes May 1 - USARA
members may subtract $8
MISSION (18 hour)
TEAM: $120 per person (3-person team) / $130
per person (2-person team)
SOLO: $140
TEAM: $60 per person (3-person team) / $65
per person (2-person team)
SOLO: $70
ALL ATHLETES MUST
SIGN LIABILITY RELEASE..
Mail entry
with check payable to: DINO LLC, PO Box 36395, Indianapolis IN 46236
TEAM: Co-ed___ All
Male___ All Female___ or SOLO___
Team
members must send entry forms together and use same Team Name at the bottom of
this form.
AGE: _____ SEX:
M__ F__
LAST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
FIRST
NAME:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
STREET
ADDRESS:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
CITY:
ZIP: |__|__|__|__|__| PHONE#: (____)|__|__|__-__|__|__|__|
E-MAIL: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
T-SHIRT
SIZE:
S___ M___ L___ XL___
USARA # (if applicable): |__|__|__|__|__|__|
EMERGENCY
CONTACT INFO:
NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
PHONE#: (____)|__|__|__-__|__|__|__|
OPTIONAL:
TEAM/SPONSOR: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
OCCUPATION: _______________ TIDBIT
ABOUT YOURSELF: _____________________________
In
consideration of being allowed to participate in the
2012
MISSION Adventure Race:
1.
Acknowledge
and fully understand that each participant will be engaging in activities that
involve risk of serious injury, including permanent disability and death, and severe
social and economic losses which might result not only from their own actions,
inactions or negligence but the actions, inactions or negligence of others, the
rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not
known to us or not reasonably foreseeable at this time. Assume all the foregoing risks and accept
personal responsibility for the damages following such injury, permanent
disability or death.
2.
Release,
waive, discharge and covenant not to sue the volunteers and organizers of this
event, if applicable, owners and leasers of premises used to conduct the event,
all of which are hereinafter referred to as “releasees”,
from any and all liability to each of the undersigned, his or her next of kin
for any and all claims, demands, losses or damages on account of injury,
including death or damage to property, caused or alleged to be caused in whole
or in part by the negligence of the releasee or
otherwise.
3.
This
event will require the participants to run and bicycle on rugged and uneven
hiking trails, paved and gravel roads open to vehicular traffic, paddle canoes
or kayaks on potentially hazardous waterways, complete ropes events at
substantial heights, and complete surprise special tests. The participants understand that the event
will be held rain or shine in unpredictable weather conditions. Weather may affect the safety level of the
various running, cycling, paddling and surprise activities and the participants
will need to use their own judgment in determining their acceptable risk
tolerance. Participants are strongly
encouraged to carry their own personal medical insurance and understand that in
the event of needing medical assistance they shoulder the full liability for
such costs.
4. Any damage to rented boats is the
financial responsibility of the race participant. The race organizers are
acting as a rental agent only for this equipment.
THE
UNDERSIGNED HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTANDING THAT I/WE
HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY.
PARTICIPANT NAME
(PRINTED) SIGNATURE DATE
______________________________ ____________________ _____
If participant is under
18 years of age…
PARENT/ GUARDIAN NAME
(PRINTED) SIGNATURE DATE
______________________________ ____________________ _____