Printable Registration for the 2013 Mountain High Outfitters, Birmingham Stage Race
Mail entry to: Birmingham Stage Race Make check payable to: Southeastern Trail Runs Please fill out completely and neatly. Please provide one form for each entrant. First Name: ___________________________ Last Name: __________________________ Gender: _______ Age on Race Day: _________ Date of Birth: __________________ Email Address: _____________________________________________________________ Phone #: ______________________ Emergency Contact # for Race Day: _______________ Street Address: _____________________________________________________________ City/State/Zip: ________________________________________________________________ Stage Race Entry $ 90.00 o Enter Two Day Stage Race (Sat-Sun) $ 70.00 o Please select stage: Stage 1, Stage 2, Stage 3 Price increases $10.00 after September 1, 2013 $ 10.00 o Shirt Size S M L XL Total Enclosed $ _________ Shirts are not available for late registration. We can order additional shirts at $15.00
Waiver Agreement: I, Individually, (and/or as a parent or guardian of named minor) for and in consideration of acceptance of this entry in the aforementioned event, do hereby release, remiss, waive and forever discharge Mountain High Outfitters Birmingham Stage Race, Mountain High Outfitters, David Tosch, Christopher Groom, Fleet Feet Sports of Birmingham, Ruffner Mountain Nature Center and Park, Red Mountain Park, Oak Mountain State Park and any other supporting groups of this said racing event, together with all their officers, agents, official employees, from any and all liability, claims, demands, actions and causes of action whatsoever arising out of, or relating to injury, illness, loss or damage, including death, relating to participation in the aforesaid event. I further state I am in proper physical condition to participate in this event. In addition, I agree that my participation in this event requires that I will not participate with roller blades, baby joggers, skateboards, animals, or anything which the race director deems dangerous to me or other participants and that the race director may remove me from this event for a violation of said policy. I further grant permission to this race and the organization(s) conducting the race and/or agents authorized by them to use any photographs, videotapes, motion picture recordings and any other record of this event for any purpose. I also agree that if the event is canceled for any reason that all entry fees are non-refundable. The race management reserves the right to deny entry to anyone not demonstrating an appropriate background in endurance activities which would not allow them to complete the race in a safe and timely manner. I also grant permission for Mountain High Outfitters to use my name and photographic likeness (or that of named minor) in all forms and media for advertising, trade, and any other lawful purposes.
Severability. If any provision of this Liability Waiver shall be unlawful, void, or for any reason unenforceable, then that provision shall be deemed severable from this Liability Waiver and shall not affect the validity and enforceability of any remaining provisions.
Waiver Agreement: I, individually, (and/or as a parent or guardian of named minor) for and in consideration of acceptance of this entry in the aforementioned event, do hereby release, remiss, waive and forever discharge claims.
Entrants under 18 year of age must have the waiver agreement signed by themselves and their parent of legal guardian.
SIGNATURE _______________________________________ Date_________________
Unsigned entries will not be accepted. Parents must sign for children under 18-years-old.
SIGNATURE OF PARENT OR LEGAL GARDIAN IF ENTRANT IS UNDER 18: ________________________________________
PRINT NAME OF PARENT OR LEGAL GARDIAN IF ENTRANT IS UNDER 18: ____________________________________________________________