Go Run
January 2012 Training Program
Registration Form:
Name:___________________________________________
Address:_________________________________________
City_______________________State:________Zip:_______
E-mail:___________________________________________
Home #:____________________Cell #:_________________
Birthday:___________________
Age:__________ Gender: M F
T-shirt Size: XS S M L XL 2X 3X
In consideration of my participation in the Go Run Program I, and on behalf of my survivors and heirs, hereby release, waive, discharge, and covenant not to sue Go Run, their officers, servants, agents, employees or trainers from any and all liability, claims, demands, action, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, whether caused by the negligence of the releasees, or otherwise while participating in such activity, or while in or upon the premises where the activity is being conducted. I also give my permission for any emergency medical care or treatment by a physician, hospital, or medical care facility that my be required, including transportation, and accept responsibility for all the cost.
Sign:_____________________________________Date:______
(parent or guardian if under 18 years)
$100.00:______________
Mail the Registration & Emergency form to:
Go Run
1227 8th Street
Lake Charles, LA 70601
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