MUSCULAR
DYSTROPHY ASSOCIATION, INC.
WAIVER, RELEASE & CONSENT
WAIVER, RELEASE & CONSENT
Mail Entries to 518 Summit Trail, Boerne Tx 78006
NAME OF EVENT: RUN AT THE RANCH
PARTICIPANT(S):__________________________________ __
SHIRT SIZE: ( Circle)
Youth Small Youth Medium Adult Small
Adult
Med Adult
Large Adult
XL Adult XXL
(Xtra Chg)
DATE: SEPTEMBER 28,2013
In consideration of MUSCULAR DYSTROPHY ASSOCIATION, INC. and the
planning committee for the Run at the Ranch Benefiting Cole and
Pierce Dutton (collectively, "MDA®") permitting (me)(my child , who is under 18) to participate
in the above-named event, I hereby, and for (my)(my child's) heirs, executors,
administrators, assigns, and all legal guardians, WAIVE AND RELEASE ANY AND ALL
RIGHTS AND CLAIMS OF ANY NATURE, FOUNDED IN WHOLE OR IN PART UPON ANY TYPE OF
NEGLIGENCE, that (I)(my
child) may have against MDA, its directors, officers, employees, agents,
chapters, assignees, licensees, sponsors, volunteers and cooperating entities,
their representatives, heirs, executors, administrators, successors, and
assigns (the “Released Parties”) arising out of or resulting from any and all
injuries or damages of any nature, including death, which (I)(my child) may
suffer while taking part in the event or any activities connected with the
event. I UNDERSTAND THAT
THIS MEANS THAT I AGREE NOT TO SUE any
or all of the Released Parties in connection with the event.
Consent also is hereby given to use (my)(my child's) name, picture,
portrait, likeness, writings or biographical information (including, if
applicable, neuromuscular disease diagnosis), and audiotape and/or videotape
recordings and sound or silent motion pictures of (me)(my child) in any media
for editorial, educational, promotional, and advertising purposes, for the
solicitation of contributions, and for any other purpose in furtherance of the
corporate purposes and objectives of MDA.
By signing this document, I certify that I have read this document
and fully understand it, and that I am not relying on any statements or
representations of any Released Party. This
document shall be binding upon me, (my)(my child's) heirs, executors,
administrators, assigns, and all legal guardians (of my child).
Print Name of Participant
Signature of Participant/ Date
Home Address, City, State & Zip Code
E-mail
I affirm
that I am the parent/legal guardian of and that I have full
authority to authorize his/her participation in the above-referenced event.
(Signature of
Parent or Legal Guardian if Participant is Under
18) Date
