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Registration
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Please fill out the following form. Once completed, print and sign the form. Then
mail (with fees) to:
Western States
1001 G Street, Suite 301
Sacramento, CA 95814
Please make checks payable to: Western States ($25 for Registration and $5 for each
event)
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First Name:
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Last
Name:
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Age Range:
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Gender:
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Team Name:
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Is this a Senior Entry?:
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Events:
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I confirm:
1) I am physically healthy and able to participate in the events outlined above.
2) WESTERN STATES MASTERS is not aware of any conditions, such as asthma, that I
may suffer, and I will be responsible for carrying any necessary medical devices
(such as an inhaler).
3) Always at the site of such events, in case of a real emergency, I hereby authorize
the local hospital, doctor or other licensed medical practitioner, and Emergency
Medical Treatment personnel, to take what he/she believes are the correct procedures
as an aid to my health and well being. This permission is extended, as necessary,
to WESTERN STATES MASTERS, and any Club/Organization hosting this event, or their
employees, agents, and volunteers. If I am consious and coherent at the site and
time of a medical emergency, I will retain my right to decide medical treatment
for myself.
4) Any travel, lodging, or meals are not the responsibility of WESTERN STATES MASTERS,
which shall have no responsibility to me at all.
5) I assume all risks and hazards incidental to such club activities. I hereby release,
absolve indemnity and agree to hold harmless the team, board, organizers, coaches,
supervisors, other participants or persons organizing and running activities and
WESTERN STATES MASTERS from any claim arising out of injury.
6) I hereby recognize that my signature constitutes my participation in the WESTERN
STATES MASTERS track and field events and that I have read and understand fully
all the rules and policies. I understand and agree that I waive my rights to any
claim arising out of participation in activities for the current track and field
events. I also forever release and agree to hold harmless the coaching staff, administrators
and WESTERN STATES MASTERS for any injuries arising out of or anyway connected to
participation in such activities.
Signature _________________________________________________________________________________________________ |
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