*School Name

*Coach Name

*Phone

*Email:

Participant 1

First Name

Last Name

Gender MaleFemale

Date of Birth

Age on race day

AdultStudent

Participant 2

First Name

Last Name

Gender MaleFemale

Date of Birth

Age on race day

AdultStudent

Participant 3

First Name

Last Name

Gender MaleFemale

Date of Birth

Age on race day

AdultStudent

Participant 4

First Name

Last Name

Gender MaleFemale

Date of Birth

Age on race day

AdultStudent

Participant 5

First Name

Last Name

Gender MaleFemale

Date of Birth

Age on race day

AdultStudent

WAIVER & RELEASE:

The undersigned athlete on behalf of himself/herself and on behalf of his/her personal representative, assigns, heirs and executors hereby fully and forever releases, waives, discharges and covenants not to sue or bring any form of legal action against the Veronica Campbell-Brown Foundation or any government or statutory authority or agency whose property and/or personnel are used and all other sponsors or co-sponsors, companies or individuals related to the event (collectively called the Releasees) from all liability to the athlete and his or her personal representative, assigns, heirs and executors for all loss(es) or damages and any and all claims or demands whatsoever on account of any injury to the athlete or property or resulting in the death of the athlete whether caused by the active or passive negligence of all or any of the Releasees or otherwise in connection with the athlete’s participation in the event. The athlete represents and warrants that he/she is in good physical condition and is able to safely participate in the event. The athlete is fully aware of the risk and hazard involved in participating in the event and hereby elects to voluntarily compete in the event knowing the risks associated with the event. The athlete hereby assumes all risks of loss(es) damages or injury(ies) that may be sustained by him/her while participating in the event. Further, the athlete grants full permission to any or all of the Releasees to use any photographs, video tapes, motion pictures, recordings, and any other record of this event for any legitimate purpose. The Veronica Campbell-Brown Foundation retains the property in all photographs, video and audio material arising from the event and reserves the right to use all such images and sound as it sees fit for legitimate purposes without the athlete’s consent.

EACH PARTICIPANT (OR PARENT/GUARDIAN FOR MINOR PARTICIPANTS) MUST SUBMIT A CONSENT AGREEMENT PRIOR TO THE EVENT

Check here if you accept these terms.

*Name of Team Leader.

*Date

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