RACIN AT THE REZ

CARDBOARD & DUCT TAPE BOAT RACE

& YOUNGINS RACE
JUNE 28, 2014
Registration begins 4:00 PM
Race begins 5:00 PM
CALL 601 992 9118
FOR MORE INFO
Supports the Reservoir Ys Inclusive Camp for Special Needs Children.
Mail or drop off registration form and team waivers to:
Reservoir YMCA - 6023 Lakeshore Park, Brandon, MS 39047
I want to participate in the [] Racin At The Rez 4-person Adult Team $50 Entry
[]Float Your Boat Youth Individual or 2-person Team $10 Entry
Ages 8 - 12
Team Name:
Captain: Email:
Phone: Alt #:
Co-Captain: Email:
Phone: Alt #:

Team Member List (include Captain/Co-Captain): Waiver Atached:
(1) []
(2) []
(3) []
(4) []

I understand that each team member must have a YMCA Waiver of Liability on fle in order to partcipate in this
program. As team representatve, I am responsible for obtaining the YMCA Waiver of Liability from each team
member and providing it to the YMCA. If I do not obtain this waiver of liability, I understand that I am personally
liable for any injuries/damages/litgaton that should arise from my team members partcipaton in this actvity.

Team Representatve Signature Date

Office Use Only: Amt Pd_______ Rcpt #_________ Date_______ Clerk_______ Balance________ Paid By: Check Cash Credit Card
METROPOLITAN YMCAS of MISSISSIPPI
WAIVER OF LIABILITY
Reservoir YMCA Racin At The Rez & Float Your Boat Event

Team Name: Captain:
Partcipant Name: Email:
Phone: Alt #:

I hereby forever release, acquit, discharge and agree to indemnify and hold harmless the YMCA and all event sponsors and volunteers, as well as any
ofcers, directors, agents, employees, successors or assigns of the aforementoned partes, in additon to all other persons who are either directly, or
indirectly involved with the actvity in which my child(ren) is/are registering (collectvely the Released Partes), from any and all liabilites, claims, damag-
es and demands and all other liabilites or whatever kind of nature arising from or related to the Y actvity, including, but not limited to, any and all liabili-
tes, claims damages and demands arising from any personal injuries, loss or death occurring as a result of the Y actvity. I further agree that I will never
insttute any acton or suit, at law, in equity or otherwise, against any of the Released Partes, and will not aid in the insttuton or prosecuton of any such
acton or suit against the Released Partes which in any way involves or relates to the Y actvity. I further state that I or my child(ren) (if minor child is par-
tcipatng in a YMCA actvity) am/is/are in proper medical conditon to partcipate in and complete the YMCA actvity and is not partcipatng against doc-
tors advice, nor am I or is/are my child(ren) taking medicatons which would deter mine/their health in the partcipaton of the YMCA actvity. This Re-
lease shall be binding upon the executors, administrators, personal representatves, heirs, successors and assigns of the undersigned.
By signing below, I hereby agree to the Waiver of Liability, Disclaimer and Permission stated above.

Partcipant Signature Date
Parent/Guardian Signature if minor child Date