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2009 Toyota Plaza NLAA Road Running Series
2009 Provincial Timex® Road Running Series


SANCTIONED AND REQUIRED BY THE NEWFOUNDLAND AND LABRADOR ATHLETICS ASSOCIATION
RELEASE, WAIVER AND INDEMNITY
IN CONSIDERATION of the acceptance of my application and the permission to participate as an entrant or competitor in the

Entry Form - 31st Annual Burton´s Pond Timex®
5km Road Race
9:00 a.m. Sunday, May 3, 2009, St. John´s

FOR OFFICIAL USE ONLY
Race Number
Cash  Cheque
Processed by
PHOTO RELEASE
I hereby grant the NLAA permission to use my image in good taste in promotional materials, posters, Web sites and other merchandise. I release NLAA from all liability of any nature in the use of any electronic or film image and or audio for advertising purposes.

PARTICIPANT CONSENT FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION
The NLAA understands the importance of protecting your personal information and compliance with government regulations. The NLAA collects "public" and "personal" information such as contact information, gender and date of birth to enable us to contact you and maintain communication with you; to provide accurate results and statistics. I agree that the NLAA can collect, use and disclose personal information about myself as set out above.

I, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE THE NEWFOUNDLAND AND LABRADOR ATHLETICS ASSOCIATION, EVENT ORGANIZING CLUB, HOST VENUE, HOST CITY/TOWN and all other associations, sanctioning bodies and sponsoring companies, and all their respective agents, officials, servants, contractors, representatives, successors and assigns OF AND FROM ALL claims, demands, damages, cost, expenses, actions and causes of action, whether in law or equity, in respect of death, injury, loss or damage to my person or property HOWSOEVER CAUSED, arising or to arise by reason of my participation in the said event, whether as a spectator, participant, competitor or otherwise, whether prior to, during or subsequent to the event AND NOTWITHSTANDING that same may have been contributed to or occasioned by the negligence of any of the aforesaid.

I FURTHER HEREBY UNDERTAKE to HOLD AND SAVE HARMLESS AND AGREE TO INDEMNIFY all of the aforesaid from and against any and all liability incurred by any or all of them arising as a result of, or in any way connected with my participation in the said event.

BY SUBMITTING this ENTRY, I ACKNOWLEDGE HAVING READ, UNDERSTOOD AND AGREED to the above WAIVER, RELEASE AND INDEMNITY. I WARRANT that I am physically fit to participate in this event.
IF THIS WAIVER IS ALTERED THE REGISTRATION WILL BE REJECTED. Please fill out the form completely and SIGN below.
2009 NLAA memb#:  Gender: M  F Year of Birth:
Name:   Club:   Telephone
Mailing Address, Town  Postal Code
Entry fee for non-NLAA members includes $5 One Day Race Permit.
Registration Fee
$20.00 non-member
$15.00 NLAA member
Late Registration Fee
$25.00 non-member
$20.00 NLAA member
(if NOT a member, this race form must be accompanied by a One Day or an Annual membership form and fee)
Total fee submitted:
Emergency contact Tel.
Signature:  Date:      
(If under 19 years, Parent or Guardian or Power of Attorney to sign below) 
Please submit this form with payment by race registration deadline. DO NOT FAX IT. Unsigned forms will not be accepted. It is a criminal offense to sign someone else´s name. Print or type clearly.