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Registration
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Please fill out the following form. Once completed, print and sign the form. Then
mail (with fees) to:
Western States
1001 G Street, Suite 301
Sacramento, CA 95814
NEW! Register Online at Active.Com!
NOTE: Mail-in Registration Deadline: July 2nd, 2010
Please make checks payable to: Western States ($25 for Pre-Registration and $5 for each
event)
Event will be held rain or shine. Absolutely no refunds.
Meet Day Registration: $35.00 and $10.00 per event
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First Name:
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Last
Name:
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Age Range:
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Email Address:
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Gender:
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Team Name:
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Date of Birth:
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USATF Membership Number:
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Is this a Senior Entry?:
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Events:
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I confirm:
1) I am physically healthy and able to participate in the events outlined above.
2) WESTERN STATES MASTERS is not aware of any conditions, such as asthma, that I may suffer, and I will be responsible for carrying any necessary medical devices (such as an inhaler).
3) Always at the site of such events, in case of a real emergency, I hereby authorize the local hospital, doctor or other licensed medical practitioner, and Emergency Medical Treatment personnel, to take what he/she believes are the correct procedures as an aid to my health and well being. This permission is extended, as necessary, to WESTERN STATES MASTERS, and any Club/Organization hosting this event, or their employees, agents, and volunteers. If I am conscious and coherent at the site and time of a medical emergency, I will retain my right to decide medical treatment for myself.
4) Any travel, lodging, or meals are not the responsibility of WESTERN STATES MASTERS, which shall have no responsibility to me at all.
5) I assume all risks and hazards incidental to such club activities. I hereby release, absolve indemnity and agree to hold harmless the team, board, organizers, coaches, supervisors, other participants or persons organizing and running activities, USATF, and WESTERN STATES MASTERS from any claim arising out of injury.
6) I hereby recognize that my signature constitutes my participation in the WESTERN STATES MASTERS track and field events and that I have read and understand fully all the rules and policies. I understand and agree that I waive my rights to any claim arising out of participation in activities for the current track and field events. I also forever release and agree to hold harmless the coaching staff, administrators and WESTERN STATES MASTERS for any injuries arising out of or anyway connected to participation in such activities.
7) I understand that there will be no refunds.
Signature _________________________________________________________________________________________________
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