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Team Name (if applicable)___________ Team Capt._________________

First Name : __________________Last  Name:____________________

Address :  ______________________________________

City  : _____________________  State : _____Zip Code:___________

Date of Birth: __/___/___ Sex:   M ___  F ___ T-Shirt:  S    M   L  XL  XXL                                                                                                                                                                                                                                                                                              (circle one)

Contact Phone  Number: ____-____-_______Email: ________________

Name & Number of Emergency Contact: ____________________ 

 

Phone Number:____-______-______

 

ACCIDENT WAIVER AND RELEASE OF LIABILITY

I acknowledge that the Phillips Chain of Lakes Tri is an extreme test of a person’s physical and mental limit and carries with it the potential for death, serious injury and property loss.  The risks include, but are not limited to, those caused by terrain, facilities, participants, spectators, volunteers, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration.  I herby assume all the risks for participating in this event.  I certify that I am physically fit, have sufficiently trained for participation in the Phillips Chain of Lakes Tri, and have not been advised otherwise by a qualified medical person.  I acknowledge that this Accident Waiver and Release of Liability (AWRL) will be used by the event holders, sponsors and organizers, in which I may participate and that it will govern my actions and the responsibilities at said event.  In consideration of my application and permitting me to participate in the Phillips Chain of Lakes Tri, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors and assigns as follows: (A) Waive, Release and Discharge from any and all liability for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter accrue to me or my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSON(S) City of Phillips, Price County, Timing is Everything, L.L.C., their directors, officers, employees, volunteers, representatives and agents, the event holders, event sponsors, event directors, event volunteers; (B) Indemnify and Hold Harmless the entities or person(s) mentioned in this paragraph from any and all liabilities or claims make by other individuals or entities as a result or my actions during the Phillips Chain of Lakes Tri.  I hereby consent to receive medical treatment, which may be deemed advisable in the event of injury, accident and/or illness during the event.  This AWRL shall be construed broadly to provide release and waiver to the maximum extent permissible under the applicable law:

I hereby certify that I have read this document and I understand its content. Race Rules will be sent when registration is received.

_________________________________    ____/____/______

Signature                                                                         Date

*Parent/Guardian Signature if under 18 _____________________________

Print and send this form with payment to:

Chain of Lakes Tri                         Registration also available at:

PO Box 112

Phillips, WI 54555

Make checks payable to Chain of Lakes Tri.

 

 

 

Phillips Chain of Lakes Entry Form

Short Course Individual Entry $45 after June 21 $55

Short Course Relay Entry $75 after 6/21 $90 (all 3 team members must fill out this form)  Registration fees include shirt and catered lunch and other packet items.

Phillips  Chain of Lakes Tri

Register online at: