13th Annual
Fun Walk/Run Just for the Health of It!
Free To All Registered Delegates and Guests Thursd
ay, O
Hosted By SDML Sponsored Risk Sharing Pools: j SDML Workers’ Compensation Fund j South Dakota Public Assurance Alliance j Health Pool of South Dakota
ctober th j Rou 6 te begin s and e at Foun n d d s ers Par j Mee k t in Hotel lothe Ramkot for a rid bby at 6:30 a am e j Star ts at 7: 00 am j 5K R oute
Registration Due to the SDML Office By September 8th 1 Entry Form Per Participant - make additional copies as needed. (Please Print)
Name_____________________________ City_______________________________ Adult T-Shirt Size: ___S ___M ___L ___XL ___XXL RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND INDEMNITY AGREEMENT AND CONSENT TO MEDICAL TREATMENT By my signature below, I acknowledge that I am aware of, appreciate the character of, and voluntarily assume the risks involved in participating in the 2016 13th Annual Walk/Run at the 2016 South Dakota Municipal League Annual Conference in Rapid City. By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal representatives, and agents, I hereby: 1. Waive any claim or cause of action against and release from liability the South Dakota Municipal League, SDPAA, SDML WC Fund and the HPSD, its officers, employees, and agents for any liability for injuries to my person or property resulting from my participation in the activity listed above; 2. Agree to indemnify and hold harmless the South Dakota Municipal League, SDPAA, SDML WC Fund and the HPSD, its officers, employees, and agents for any claims, causes of action, or liability to any other person arising from my participation in the activity listed above; and 3. Consent to receive any medical treatment deemed advisable during my participation in the activity listed above. I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND INDEMNITY AGREEMENT AND CONSENT TO MEDICAL TREATMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. Name ____________________________________________________________ Date of Birth __________________________ Signature __________________________________________ Address _____________________________________________ I HAVE READ THIS RELEASE.
Signature of Guardian if under the age of 18 ___________________________________________________________________ I HAVE READ THIS RELEASE.
