Brookings Area Senior Games Registration Form â—? July 20 & 21, 2018 Name: _______________________________________________________ Male ___Female ___ PLEASE PRINT
(LAST)
(FIRST)
(MI)
Address: __________________________________________ Home Phone: ____________________ City____________________ State__________ Zip__________ Cell Phone: ____________________ Email Address (print in all caps) ___________________________________________________________________________________________ Birth Date (mm/dd/yyyy): __________________ 50-54
55-59
60-64
Circle your age category (as of 12/31/2018)
65-69
70-74
Waiver and Hold Harmless Agreement I, the undersigned participant, hereby waive and release any and all claims or causes of action arising out of any injuries I may sustain as a result of my participation in the 2017 Brookings Area Senior Games, including those attributable to negligence and/or weather conditions. This waiver and agreement shall indemnify, and hold harmless the City of Brookings and its officers, officials, employees, agents and volunteers and the Brookings Area Senior Games leadership and volunteers, from and against all claims, damages, losses and expenses, including but not limited to, attorneys’ fees, arising out of or resulting from my participation in the Brookings Area Senior Games and shall be binding upon me and my heirs, personal representatives and assigns. Publication Release In participating in the Brookings Area Senior Games, I am specifically granting permission to you to use the likeness, voice and words of myself in television, radio, films, newspapers, magazines and other media and in any form not heretofore described, with the intent of communication the purpose and activities of the Brookings Area Senior Games without my remuneration. I certify that I have read and agree to the above entry information. SIGN HERE
SIGNATURE
DATE
75-79
80-84
85 +
PLEASE COMPLETE BOTH SIDES OF ENTRY FORM! Advance registration deadline is Friday, July 13th. Advance registration is strongly encouraged but not required (except for 8-ball pool). Registration packets including a map of locations can be picked up at the Brookings Activity Center, 320 5th Avenue from noon to 4 on Friday and at the event sites on Saturday. For additional information, call the Brookings Activity Center at 605-692-4492 or the Brookings Park and Recreation Office at 605-692-2708. You may also e-mail us at tsaugstad@cityofbrookings.org.