The 1st Annual Deep Blue 5k Swim, Metric Mile
Swim, and Ocean Festival
You may print this form
or Enter
Online by CLICKING HERE.
All swimmers
must complete this form and sign the Liability Release. The US$65.00 entry
fee includes: swim entry, welcome dinner, T-Shirt, and swim cap. All
entries must be received by the Entry Deadline of November 1st,
2001!
Name: ________________________________,
___________________________________
Last,
First
Address: __________________________________________, ________________, _____, ______ _________
Street, City, State, Zip Code Country
Daytime phone: ________________, Evening phone: _________________, E-Mail: _________________
Sex: Male
/ Female Date of Birth: ____/____/____ Age on Race Day: ______
Circle
one MM DD YY
Circle only one event: Deep Blue 5k solo swim M /
F
Deep
Blue 5k with fins M /
F
Metric
Mile solo swim M /
F
Metric
Mile with fins M /
F
If you have kids that will be participating in the Kids Fun Swim, please let us know. There is no entry fee for the Kids Fun Swim. Official registration will be on-site on race day. How many? ____ boys / ____ girls
AUTHORIZATION AND EVENT PROMOTION:
I agree to be filmed and photographed by the
official and authorized photographers of this event under the conditions
authorized by the Host and Meet Directors, and give the event organizers (host
and meet director) the right to use my name, picture, likeness, and
biographical information before, during and after the period of my
participation in this event to promote the event in which I compete or to
promote the success of the team on which I competed. I will not promote
third party sponsors, causes, or charities unless pre-approved by the Meet
Director.
LIABILITY RELEASE:
I, the undersigned participant, intending to be legally bound, hereby certify that I am physically fit and have not been otherwise informed by a physician. I acknowledge that I am aware of all the risks inherent in swimming (training and competition) including possible permanent disability or death, and agree to assume all of those risks. AS A CONDITION OF MY PARTICIPATION IN THIS SWIMMING EVENT OR ANY ACTIVITIES INCIDENT THERETO, I HEREBY WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES INCLUDING ALL CLAIMS FOR LOSS OR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING: AQUA MOON ADVENTURES, THE CLUBS, HOST, MEET DIRECTORS, MEET SPONSORS, MEET COMMITTEES OR ANY INDIVIDUALS OFFICIATING AT THE MEETS OR SUPERVISING SUCH ACTIVITIES. I further agree to abide by and be governed by the rules and regulations of this event. I also specifically acknowledge that: 1) I am aware of all the risks inherent in open water swimming and agree to assume those risks and 2) I understand that Events outside of one's country present many types of additional risks. Finally, I understand that there will be no refunds given for any reason including event cancellation. I have read this entire Liability Release and understand its content without exception.
Swimmer’s Signature: ____________________________________ Date: _______________
Parent’s Signature: _______________________________________ Date: _______________
(required for swimmers age 18 and
under)
------------------------------------------------------------------------------------------------------------------------
Entry Fee for each swimmer is US$ 65.00 = US$
65.00
Swimmers T-Shirt, circle one (included with entry
fee): M
/ L / XL
To purchase additional T-Shirts (US$15.00 each), please indicate
sizes & amounts:
M____ / L____ / XL____ Total # of additional
T-Shirts ______ x US$15.00 =
US$_________
Additional guests for Welcome Dinner (US$12.00 each): # of guests: ______ x US$12.00 = US$_________
Total Fees enclosed (swimmer entry fee, additional T-Shirts, additional dinners): US$ ____________
All fees are non-refundable. Incomplete entries
will not be accepted.
Make checks payable in (US$) to Aqua Moon
Adventures and mail with both pages of this completed and signed entry form
to: Aqua
Moon Adventures, P. O. Box 9448, Coral Springs, Florida 33075 USA