Print and mail with check.
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Name ___________________________________________________ Phone _____________________________________ Address ___________________________________________________ City ____________________________ ST ______ Zip ____________ Age (Day of Race) _________ Sex ______ T-shirt size_____ In consideration of my entry being accepted, I intend to be legally bound, and do hereby, for myself, my heirs, executors, waive and release any and all rights and claims for damages which I may hereinafter accure to me against the city of Cocoa Beach, and all other sponsors, contributors, or any subsidiary or political division thereof, its or their respective officers, representatives, successors and assigns for any and all damages or injuries which may be sustained and suffered by me in connection with my association with entry of participation in the “9th Annual Space Coast Cross Country Jamboree.” If I should suffer injury or illness I authorize officials of the race to use their discretion to have me transported to a medical facility and I take full responsibility for this action. I attest and certify that I am physically fit and have sufficiently trained for competition in this event. I have read the above and understand that I am entering this event at my own risk. Date ________________________ Signature ___________________________________________ _________________________________________________ |
$3 pre-registered, $5 day of race.
Return to: Dan Sage, 1206 Sugar Creek Lane, Rockledge, FL 32955
