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Leap Registration Form

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Literacy Center of Milford, Inc.

Register for the Leprechaun Leap
March 20, 2010
Free T-Shirt
with a $25.00 minimum pledge

Full Name:
Address - City, State:
Age
E-Mail Address:
Phone Number:
How did you hear about the Leprechaun Leap?
Who are you "leaping" for?
Even after registering online, you will still need to stop by the check-in table at 2:00 P.M. on the day of the Leprechaun Leap to turn in your pledges and sign a waiver. Please check the box if you understand.
By registering for this event, you are agreeing to allow The Literacy Center of Milford use of all event-related photography and video for marketing needs. Check the box if you understand.
Waiver and Release: Read the waiver below and check the box if you understand.
  

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY, AND PARENTAL CONSENT AGREEMENT ("AGREEMENT")

In consideration of being allowed to participate in the Leprechaun Leap, I hereby represent that I understand the nature of the Leprechaun Leap event and that I am, or my minor child is, in good health and proper physical condition and that my minor child is of sufficient age and discretion to take part in this event. Either I or my minor child will be solely responsible for determining whether event conditions are safe for participation and for discontinuing participation, if the conditions are believed to be unsafe.

I fully understand that the Leprechaun Leap event may involve risks, foreseen and unforeseen, of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my actions or those of my minor child, the actions or negligence of others participating in the event, or the conditions at the time of the event. I fully accept and assume all such risks and responsibility for losses, costs, and damages I or my minor child may incur as a result of participation in this event.

I hereby release and discharge and covenant not to sue The Literacy Center of Milford, or its agents, volunteers, or officers, any sponsors or advertisers, (hereinafter the “Releases”) from all liability, claims, demands, losses or damages on my account or that of my minor child caused or alleged to be caused in whole or in part by the negligence of the Releases or otherwise, including negligent rescue operations; and I further agree that

If, despite this agreement, anyone on my or my minor child’s behalf, makes a claim against any of the Releases, I will indemnify, save and hold harmless each of the Releases from any loss, liability, damage, or cost which may incurred as the result of such claim.

I have read this Release and Waiver of Liability, Assumption of Risk and Parental Consent Agreement, I understand all of its terms and that I have given up certain rights by signing it. I have signed it of my own free will, without any inducement by any other party and intend it be a complete and unconditional release to the extent allowed by law. If any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.

Even after registering, you will still need to stop by the check-in table on the day of the Leprechaun Leap. By registering for this event, you are agreeing to allow The Literacy Center of Milford use of all event-related photography and video for marketing needs.

Please check the box above, acknowledging that you understand this waiver and to complete the online registration form.

 


Literacy Center of Milford
Fannie Beach Community Center
16 Dixon St.  Milford, Ct. 06460
203-878-4800

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