ࡱ>  >2bjbj 32| | $.000000$ 5#|TQ"Tjjj..j.jjVv@SD&:(0 #.<##0jTTj#| :  SLAVE to the GRIND II SKATEBOARD COMPETITION REGISTRATION FORM Please check off the age group you wish to enter: ۉ Under 12 ۉ 16 & over ۉ 12-15 Please check of the class of competition you wish to enter: ۉ BEGINNER ۉ AMATEUR Participant Information: Name:_______________________ _____________Age:___ E-mail:_______________________Phone: ________________ Address:____________________________________Postal Code:________ Date of Birth: _____/____/_______ Male Female Day Month Year Emergency Contact Information: Name: _________________________________ Relationship: ____________ Phone: _______________ Name: _________________________________ Relationship: ____________ Phone: _______________ Parent/Guardian Information: (If under the age of 18, age on day of event: September 19th 2009): Name: _____________________________________ Phone No.: ___________________ Name: _____________________________________ Phone No.: ___________________ Fee: $10 Cash Only (must be paid before participant can compete) Fee Collected: ۉ YES ۉ NO ***NB: The attached INFORMED CONSENT, INDEMNITY & RELEASE MUST be read, completed and signed by all who wish to participate INFORMED CONSENT, INDEMNITY AND RELEASE THIS FORM MUST BE FILLED OUT COMPLETELY AND SIGNEDIF YOU WISH TO PARTICIPATE IN THE EVENT If the Participant is under the age of 18, it must be filled out and signed by a parent or legal guardian. SITE: The Town of Smiths Falls is the owner of a skateboard/BMX facility located behind the Arena The bears den, in the town of Smiths Falls. EVENT: On September 19th, 2009 the Skateboard Competition that is taking place at the Smiths Falls Site; PARTICIPANT: ___________________________________________________ [Print name of participant here](the Participant) wishes to participate in the Event. THIS INFORMED CONSENT, INDEMNITY AND RELEASE WITNESSES THAT, in consideration for the Participant being able to participate in the Event, the Participant and/or the Legal Guardian agrees that the Participant shall to do so on the terms and conditions provided below: I, as the Participant, (or the parent or legal guardian of the Participant on behalf of the Participant), understand that skateboarding, BMX and in-line skating involve risk of injury, including cuts, bruises, sprains, fractures, spinal injury, and even death; understand that these risks can happen just due to the nature of these activities and with no fault of the other participants, the town or the sponsors of the Event; understand that the risk may be reduced if I participate within my ability level, stay aware of all surroundings and other participants, and wear proper safety equipment; understand the above risks and I agree that I am participating in this Event at my own risk, and accept the risks outlined above; will wear an approved helmet at all times that I am participating in the Event; agree that the other protective gear that I wear is my own decision, and whether I choose to wear it or not, I do so at my own risk; am medically able to participate in the Event, and agree that if one of the judges decides that I am not medically able and cannot participate, I will abide by that decision and not participate; agree that the judges decision regarding the outcome of the Event is final and I agree to abide by their decision; agree to obey and observe all rules and regulations that apply to the Event and any laws, regulations, and by-laws of the City, the province or Canada that may apply, and if I do not, I may be removed from the Event; that the Event may be cancelled and not rescheduled, and to abide by that decision; am aware that my photo may be taken at the Event, and that any such photo may be used after the Event for purposes such as the promotion of other events; authorize the organizers of the Event, City staff, or other qualified personnel at the Site, to provide medical care to me if they deem it necessary and appropriate, including transporting me to the hospital by ambulance, and that I will be responsible for any associated costs; that the Town, and any of its elected officials, employees, officers, agents or servants, or others for whom the Town is responsible at law, or the Running Goat, or Youth in Power, and all other sponsors and participating organizations shall not be liable in any manner whatsoever for any suit, claim, demand, charge, action, or cause of action, by whomsoever brought or made, in respect of any loss, cost, expense, or for any injury (including loss of life), or damage to person or property, that is in any way connected to my participation in the Event, whether occurring before, during, or after the Event (Claims and Losses); agree to indemnify, save harmless, and defend (at the discretion of the Town) the Town, and any of its Council, employees, officers, agents or servants, or others for whom the town is responsible at law, or the Running Goat, Youth in Power and all other sponsors and participating organizations from and against any and all Claims and Losses. I, the Participant, have read, been informed of, and understand all of the contents of this document, and agree to be bound by it. Signature of Participant: _______________________________________________________ *.F\  * 4 6 < F ( b | : N ʿ~~mamh0uOJQJmH sH  h0u5OJQJ\^JmH sH humH sH h0umH sH h0uhuhu5aJmH sH huaJmH sH h0uaJmH sH hu5\mH sH h0u5\mH sH  h0u5\h0u5CJ\h;k5CJ\aJmH sH jh0uUh0u5CJ\aJmH sH #0`6 H ( z  < d Q ~ pdh&d7$P]p pdh7$]p$pdh&d7$P]pa$7$    <  E G I M N Q } ~ Ztz·xppdpdpdpZpKh0u5CJ\aJmH sH hAaJmH sH hAhA5mH sH hAmH sH h0u6CJH*]mH sH hn56CJ]mH sH h0u6CJ]mH sH h0u6CJ]aJmH sH h0umH sH h0u5\mH sH .hAhA5CJOJQJ\^JaJmH sH (hA5CJOJQJ\^JaJmH sH  hA5OJQJ\^JmH sH ~ ZRNP[\a & F 7$^`7$ & F 7$^` & F ^` gd;k  pdh7$]p Ry{NUbl)P5ŶziYzYIYzYYYzYhuCJOJQJaJmH sH h0uCJOJQJaJmH sH !h0uCJOJQJ\aJmH sH $h0u5CJOJQJ\aJmH sH *h0u56CJOJQJ\]aJmH sH $h0u6CJOJQJ]aJmH sH h0u6CJOJQJ]aJh;kh0uCJaJh;kh0uaJ h0uaJh0u5CJ\aJmH sH "h0u56CJ\]aJmH sH 5 Anb0e011>27$ & F 7$^`5x0e0111=2>2۸۸h0uU$hu5CJOJQJ\aJmH sH $h0u5CJOJQJ\aJmH sH huCJOJQJaJmH sH h0uCJOJQJaJmH sH 'hh0u5CJOJQJaJmH sH Print name of Participant: _________________________Date Signed: ________________________________ OR I, the parent or legal guardian of the Participant, have read, been informed of, and understand all of the contents of this document, and accept all of the terms and conditions in this document as they apply to the Participant, and agree that I and the Participant shall be bound by it. 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