4 Miles 4 Diabetes - Mail-In Registration Form

Event Registration Fee: $25.00

Please make check payable to: Central Ohio Diabetes Association
You may consolidate registration fee payments for multiple participants into one check however, please complete a separate registration form for each participant.

Mail Registration to:
CODA - 4 Miles 4 Diabetes
P.O. Box 178
Delaware, OH 43015

Name
______________________________________________________________

Address
______________________________________________________________

City, State Zip Code
______________________________________________________________

Telephone
______________________________________________________________

E-mail Address
______________________________________________________________

Age on Race Day (12/02/07)
______________________________________________________________

Affiliation or Team Name
______________________________________________________________

Female     |      Male      (Circle One)

T-Shirt Size (Circle One)     Youth L    |    S   |     M    |    L    |     XL

Waiver
I agree that by participating in this physical activity, 4 Miles 4 Diabetes (the “Event”) or use of any Event facility/premises, I do so at my own risk. I assume all risk of injury, illness, damage or loss to me or my property that might result, including without limitation, any loss or theft of personal property. I consent to medical treatment in the event of injury, accident and/or illness during the Event. I agree on behalf of myself (and my personal representatives, heirs, executors, administrators, agents and assigns) to release and discharge Ultra-Fit USA, the Race Director, the City of Delaware, Ohio Wesleyan University, OhioHealth and all other event sponsors, associates and volunteers from any and all claims or causes of action (known or unknown) arising out of their negligence. I acknowledge that I have carefully read this Waiver and Release and fully understand that it is a release of liability. By my signature below, I am waiving any right that I may have to bring legal action to assert a claim against any and all Event sponsors and representatives for their negligence.

Signature
______________________________________________________________
Under 18, Signature of Parent or Legal Guardian and Participant Required

Date
______________________________________________________________