Patriots In The Park 5K Run/Walk Entry Form Name __________________________________________________ Address ________________________________________________ Phone __________________________________________________ Sex ________________           Age on Race Day _________________ T-Shirt Size - Circle One Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Extra Large ---------------------------------------------------------------------------------------- All participants must sign the waiver below. Registration Form Waiver Release of All Claims and Hold Harmless Agreement Please read this form carefully and be aware that in registering and participating in this event you will be waving all claims for injuries you might sustain arising form this event. As a participant in Granite City Park District and Gateway Regional Medical Center programs or events, I recognize and acknowledge that there are certain risk of physical injury and I agree to assume the full risk of any injuries, including death, damages or loss which I may sustain as a result of participating in any and all activities connected and associated with such an event. I agree to waive and relinquish all claims I may have as a result of participating in the event against the Park District and Gateway Regional Medical Center and their officers, agents servants and employees. I do hereby fully release and discharge the Park District and Gateway Regional Medical Center and its officers, agents, servants, and employees from any and all claims from injuries, including death, damage or loss which I may accrue to my participation in this event. I further agree to indemnify and hold harmless and defend the Park District and Gateway Regional Medical Center and their officers, agents, servants and employees from any and all claims resulting from injuries, including death, damages and losses sustained by me and arising out of, connected with, or in any way associated with the activities of the event. ______________________________________________ Name of Participant ______________________________________________ Date _______________________________________________ If participant is under age 18, parent or guardian must sign form _______________________________________________ Date       PRINT NAME AS IT APPEARS ABOVE _______________________________________________