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Registration Form
1. Completely fill out this form
2. Read and sign the waiver below
3. Print and mail earl with non-refundable $10
registration fee payable to University of Michigan to:
Shelly Morell, Event Coordinator
32591 Judy
Westland, Michigan 48185
e-mail: smorell@wowway.com
web page: www.secondchanceatlife.org
***Coming Soon: .pdf file on U of M's website for downloading**
Name: _______________________________
Address: ____________________________
City, State, Zip: ___________________
e-mail: _____________________________
Age/gender: _________________________
T-Shirt size: __M __L __XL ___XXL __S(Child)
__ $10 registration fee enclosed ($15 day of walk)
__ $20 registration fee 5K enclosed ($25 day of run)
$___(make check payable to University of Michigan)
Waiver/Release Form (please read and sign)
The undersigned named entrant, and the parent or guardian on behalf of any named entrant who is under the age of 18(the "participant") for an in consideration of being able to enter the Second Chance At Life Walk/5K Run ("event"), hereby released and forever discharges the Regents of the University of Michigan ("University")(which includes the University of Michigan Transplant Center), all of the colunteers, agents, employees, insureres, sponsors, and representatives of the Univeristy and any or all other persons, firms, or corporations who may be claimed to be liable ("releasees") of and from any and all liability for any injury, harm or other loss or damages suffered whatever,either at this known or unknown, which the participant has or may have against the releasees, b ased upon or arising out of any act, omission or occurence with respect to the event or any of the activities of the University.
The participant furhter attests and verififes that the he/she, or named entrant, is a capable, experienced, accomplished and physically fit athlete who is able to participate in the event. An adult must accompany participants under the age of 18 years of age. The participant specifically acknowleges that there are dangers inherent to running, walking, cycling and skating on public roads and that the releasees have no control over, nor responsibliites for such danagers.
Signature ___________________________________
Signature of parent or guardian (under age 18)
_____________________________________________
Emergency Contact/Phone Number
_____________________________________________
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