Granite City Group Fitness 5k Fun Run & Walk

Granite City Group Fitness 5k Fundraiser Informed Consent Form REGISTRATION, WAIVER and RELEASE OF LIABILITY Name of Participant (First and Last): Mailing Address: Physical Address: City: State: Zip: Home Phone: Cell Phone: Emergency Contact Name: Phone: Email Address: How did you hear about this race? General Statement of Program Objectives and Procedures: I understand that this physical fitness program includes exercises to build the cardiorespiratory system (heart and lungs), the musculoskeletal system (muscle endurance, strength and flexibility, and to improve body composition (decrease of body fat with an increase in weight of muscle and bone). Exercise may include aerobic activities (running, walking and other similar activities),and callisthenic exercises for muscular strength. Description of Potential Risks: I understand that the reaction of the heart, lung and blood vessel system to exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during or following exercise which may include abnormalities of blood pressure or heart attacks. Use of engaging in body calisthenics may lead to muscle strains, pain and injury. I further understand that the trainer shall not be liable for any damages arising from personal injuries sustained by me while and during the 5k race. | hereby fully and forever release and discharge Brittany Tullar, its assigns and agents from all claims, demands, damages, rights of action, present and future herein. I understand the warrant, release and agree that I am in good physical condition and I have no disability, impairment or ailment preventing me from engaging in this 5k race that will be detrimental to my health, safety, comfort or physical conditions if I engage or participate. | state that I have had a recent physical checkup and have my personal physician's permission to engage in aerobic and/or anaerobic programming. Granite City Group Fitness 5k Fundraiser Informed Consent Form REGISTRATION, WAIVER and RELEASE OF LIABILITY ΡΑGΕ TWO Indemnify and hold harmless Brittany Tullar, her elected and/or appointed officials, employees, students, agents and volunteers, from any and all liabilities or claims made by other individuals or entities as a result of or relating to my participation in this activity. Therefore, intending to be bound and as a condition of being allowed to participate in this 5k race, I have freely signed this Agreement and Waiver/Release of Liability. AGREEMENT AND WAIVER / RELEASE OF LIABILITY Participant Signature Date ______________________ Parent/Guardian Signature (Required if Participants under 18 years old)_______________ Date ______________________ Print Parent/Guardian Name: _____________________ SecureFee™ Registration Cancellation Insurance is offered in most states. If purchased, your registration may be covered for one of the covered reasons stated in the policy.