JASON KREMERS KICKING CANCER CIRCUIT CHALLENGE

A fundraising event to help support Jason Kremers fight against Non-Hodgkins Lymphoma Name: __________________________________________________________________________________ Phone: ___________________________ DOB: ______________ Email: ___________________________________________

Emergency Contact Info: __________________________________________

$35 entry fee Paid: Cash Check

INFORMED CONSENT/WAIVER AND RELEASE: I,__________________________hereby understand and acknowledge that the Jason Kremers Kicking Cancer Circuit Challenge may expose me to many inherent risks, including accidents, injury, illness, or even death. I assume all risk of injuries (including death), illness, or damage associated with participation including, but not limited to, falls, exercise, contact with other participants, and all other such risks being known and appreciated by me. I assume full responsibility, during and after my participation, for my choices to use or apply, at my own risk, any portion of the information or instruction I receive. I hereby acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with participation in physical activity. I acknowledge that I am physically fit and mentally capable of performing the physical activity I choose to participate in. I agree that I am voluntarily participating in this event and voluntarily using these activities, instructions, facilities, programs, services and I assume all risk of injury (including death), illness, damage or loss to me or my property that might result there from, without limitation. I agree on my own behalf (and my personal representatives, heirs, executors, administrators, agents and assigns) to release and discharge Joshua Field, Victoria Adelus, Xcel Fitness, Team ABC, Brian McLaughlin, (and their affiliates, employees, agents, representatives, successors and assigns) from any and all claims or causes of action (known or unknown) whether or not arising out of the negligence of Joshua Field, Victoria Adelus, Team ABC, Brian McLaughlin, and/or Xcel Fitness. This Waiver and Release of liability includes, without limitation, injuries (including death) which may occur due to maintenance levels of any exercise equipment or facilities, any negligent instruction, nutrition or workout programs, supervision, and any other cause. After having read this waiver and knowing these facts, and in consideration of acceptance of my participation, I agree on my own behalf (and my personal representatives, heirs, executors, administrators, agents and assigns) to HOLD HARMLESS, WAIVE AND RELEASE Victoria Adelus, Josh Field, Brian McLaughlin, Team ABC, Xcel Fitness and their officers, affiliates, agents, employees, representatives, and successors from any responsibility, liabilities, demands, or claims of any kind arising out of my participation in their programs and/or events, including but not limited to, Jason Kremers Kicking Cancer Circuit Challenge. I acknowledge that I have carefully read this Waiver and Release, that I fully understand that it is a release of liability, and I signed it voluntarily. I am waiving any right that I may have to bring legal action to assert a claim against Joshua Field, Victoria Adelus, Brian McLaughlin, Team ABC, and/or Xcel Fitness.
Signature Date

Entries may be returned to the following locations: Max Muscle, Xcel Fitness, Bend Barbell, & the Wellness Doctor

Please make checks payable to: Jason Kremers Cancer Fund For tax purposes use EIN #: 46-3960121