Last Name First Name Age on Sex
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Oct. 4 M/F
Mailing address (include apt. # and c/o)
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City and State Zip/Postal Code
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Birth date Area Code Telephone
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Mo Day Yr
E-Mail Address
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Shirt Size Small |__| Medium |__| Large |__| X Large |__|
WAIVER. Knowingly and at my own risk I do hereby apply to enter an athletic
contest. I hereby agree that I release and discharge Grand Itasca Foundation, Vacation Sports, and all other parties associated with
Kickin' Leaves Duathlon from all claims, demands, injuries, damages, actions or causes of action from all acts of active or passive negligence
on the part of such corporations, organizations, clubs, their servants, agents or employees, and hereby assume all the risks
associated with my participation in the event. Further, I hereby grant full permission to any and all of the foregoing to use my name,
likeness and voice, as well as any photographs, videotape, motion pictures, recordings and any other record of this event in which I may appear
for any legitimate purposeincluding broadcast of the event, the reuse in any media of this broadcast and in advertising and promotion.
Signature
(by parent or guardian if
participant is under 18) ___________________________________________________
NO REFUNDS
Kickin' Leaves Duathlon
Grand Itasca Clinic & Hospital
1601 Golf Course Rd.
Grand Rapids, MN 55744
Make check payable to Grand Itasca Foundation