MAKE CHECKS PAYABLE TO ANGEL’S GATE 18 Josephine Lane, Fort Salonga N.Y. 11768
First Name________________________________ Last Name______________________________ Registration fee amount enclosed $___________
Age ( on race day)_____________________ Date of Birth______/_____/______ Male ____ Female___ Additional contribution (optional) $ _________
_
Address _____________________________________ Phone 1 # ____________________ Phone 2 #____________________ Total $_____________
Town _______________________________________ State ___________ Zip _________ email address_____________________
Complete entry form, sign below after reading the following statement. I, the undersigned intending to be legally bound, hereby for myself, my heirs, executors and administrators, wave and release and hold harmless ANGEL’S GATE HOSPICE FOR ANIMALS, THE COUNTY OF SUFFOLK, THE KINGS PARK SCHOOL DISTRICT, Isaland Timing, all race sponsors, the police and volunteer Fire Department of Kings Park and their representatives, for any and all liabilities, claims, demands and causes of action arising directly or indirectly from my participation in this event, even if any such liabilities, claims, demands and causes of action arise in whole or in part out of the negligence or any of the above mentioned organizations or individuals. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event and that my physical condition has been verified by a licensed Medical Doctor. If signed by a parent, the parent agrees to release and hold the above-named organizations and personnel harmless of any claims and rights which may be assigned on behalf of the entrant. Further, I hereby grant permission to any and all of the foregoing to use photographs videotapes, motion pictures, recordings or any other record of this event for any purpose whatsoever.
The chip you recieve is the property of Island Timing. You agree to return the chip or be billed $20.
Signature (parents sign for children under 18 yrs)_________________________________________________________________________ Date _________________
Special Category ( Check , if applicable) : Wheel Chair__________ Fun Run_______
