Individual Registration Form

Important: Please fill out one form for each  person.  Make checks payable to and mail to:

Four Seasons YMCA

106 Gratton Road, Tazewell VA, 24651

Name: _______________________________

Address:______________________________

_____________________________________

Phone: _______________________________

Email: _______________________________

Age:_______ Birthday:__________________

Emergency Contact Information day of race:

Name: _______________________________

Phone: _______________________________

**Register by Sept. 3rd to receive T-Shirt

T-Shirt Size: S M L XL XXL (Circle one)

 

# of spectator Post Race Brunches __ x  $10.00 each

 

 

Waiver: I know that running, walking, and swimming a triathlon is potentially hazardous activity. I should not participate unless I am medically able and properly trained. I know that although police protection will be provided, there will be traffic on the course route.  I assume the risk of running/cycling into traffic. I am aware that there are certain risks associated with swimming in a lake even with lifeguard supervision. I accept any and all risks associated with participating in this event included but not limited to falls, contact with other participants, the effects of weather including high heat and/or humidity and road conditions, all such risks being known by me. Knowing these facts, and in consideration of your accepting my entry, I hereby for myself, my heirs, executors, administrators or anyone else who might claim in my behalf, covenant not sue, waive, release and discharge the Four Seasons YMCA, all sponsors, the State of Virginia, City of Tazewell, Tazewell County, Race Officials and volunteers, any and all claims of liability for death, personal injury or property damage of any kind or nature whatsoever, foreseen or unforeseen, known or unknown.  I also give my permission for free use of my name and picture in any broadcast/telecast/print accounts of the event. I understand that my paid entry fee is non-refundable.

Signature: ______________________________

Legal Guardian’s Signature if under 18: __________________________________

Date: ______________________________

ALL TEAM MEMBERS MUST SIGN A RELEASE FORM

 

 

 

 

 

 

Relay Team Information

Swimmer

Name: _________________________M or F

Address:___________________________

_________________________________

Age:______ Birthday:______________

Phone: ____________________________

Email: ____________________________

Emergency Contact Information day of race:

Name: ____________________________

Phone: ____________________________

T-Shirt Size: S M L XL XXL (Circle one)

 

Biker

Name: _________________________M or F

Address:___________________________

_________________________________

Age:____ Birthday:_______________

Phone: ____________________________

Email: ____________________________

Emergency Contact Information day of race:

Name: ____________________________

Phone: ____________________________

T-Shirt Size: S M L XL XXL (Circle one)

 

Runner

Name: _________________________M or F

Address:___________________________

_________________________________

Age:____ Birthday:_______________

_________________________________

Phone: ____________________________

Email: ____________________________

Emergency Contact Information day of race:

Name: ____________________________

Phone: ____________________________

T-Shirt Size: S M L XL XXL (Circle one)

Each person must fill out the waiver inside.

** All participants must register by Sept. 3rd to receive T-Shirt.

Relays:(check by appropriate space)

Male: ______      Female:_____     Mixed:_____