The
5th Annual Deep Blue 10k, 5k
& Metric
Mile Swims
You
may print this form or Register
online by clicking here
Name:
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Last, First, MI
Sex:
Male Female Date of Birth: / / Age
on race day:
Address:
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Street Apt
/ Suite #
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City State/Province Zip
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Country
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Daytime
phone Evening phone
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E-Mail
Address
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On
Circle one event only: 10k Solo M/F
Deep Blue 5k solo swim M/F
Metric
Mile solo swim M/F
Metric Mile with fins M/F
Name:
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Last, First, MI
2005
AUTHORIZATION AND EVENT PROMOTION:
I _____________________________,
agree to be filmed, photographed, taped, quoted or otherwise mentioned (without
compensation) by the Event Director (also known as Meet Director), or by anyone
authorized by the Event Director. This includes but is not limited to the
official and authorized photographers, writers, hosts, or sponsors of this
event under the conditions authorized by the Event Director. I give the Event
Director, and anyone authorized by the Event Director, the right to use (without
compensation) my name, picture, likeness, quotes, and biographical information,
whether audio or visual, before, during and after the period of my individual
or team participation in this event. I will not promote third party sponsors,
causes, or charities unless pre approved by the Event Director. I understand
that there will be no refunds given for any reason including event cancellation.
Signed:
Date:
2005
WAIVER/RELEASE OF
LIABILITY
PLEASE READ
CAREFULLY BEFORE SIGNING.
THIS IS A RELEASE OF
LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS.
I ___________________________________________________the
enrolled participant and/or the parent/guardian of the participant agree and
understand that swimming is a HAZARDOUS activity. I recognize that there are risks inherent in
the sport of swimming, including but not limited to, paralyzing injuries and
death.
The participant hereby
agrees to participate in the swimming event and associated activities and/or
programs and hereby agrees to indemnify and hold harmless: Aqua Moon Adventures
and/or its sponsors, agents, directors, officers, volunteers, and employees,
including the race committee,
against any liability resulting from any injury that may occur to the
participant while participating in The Bonaire EcoSwim events and associated
activities and/or programs. The
participant also agrees to indemnify Aqua Moon Adventures and/or its sponsors,
agents, directors, officers, volunteers, and employees, including the race
committee, for any damages incurred arising from any claims, demand, action or
cause of action by the participant.
The participant authorizes
any representative of Aqua Moon Adventures and/or its sponsors, agents, directors,
officers, volunteers, and employees, including the race committee, to have the participant treated
in any medical emergency during their participation in The Bonaire EcoSwim
events and programs. Further, the participant and/or parent/guardian agrees to
pay all costs associated with medical care and transportation for the
participant.
I have noted on the back of
this form any medical/health problems of which the staff should be aware.
I also understand that
events outside of one's country present many types of additional risks and that
the standard of care may not be what I am accustomed to. Any dispute,
controversy or claim of any kind whatsoever, including but not limited to torts
allegedly resulting in injuries during the swim race or at the hotel
facilities, shall be settled by the American Arbitration Association in
accordance with its Commercial Rules and judgment on the award rendered by the
arbitrator may be entered in any court having jurisdiction thereof. This
arbitration agreement covers all claims as set forth herein between the
undersigned and Aqua Moon Adventures and/or its sponsors, agents, directors,
officers, volunteers, and employees, including the race committee, and will
continue from the time of the acknowledgment of this agreement by the
undersigned until it is otherwise terminated in writing by the agreement of the
parties.
I HAVE CAREFULLY READ THE
ABOVE LIABILITY RELEASE AND SIGN IT WITH FULL KNOWLEDGE OF ITS CONTENTS AND
SIGNIFICANCE.
Signed:
Date:
(Participant or Parent/Guardian)
Name:
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Last,
First,
MI
Entry Deadline: In order to receive
the swim cap, tee-shirt, and dinner your entry must be received by September
30th 2005. Entries for the swim will be accepted after this date
and until October 31, 2005 but WILL NOT include a tee-shirt, swim cap, or
dinner.
Swimmers can swim one event only.
Entry Fees for the Deep Blue 10k,
5k, and Metric Mile are US$ 75.00 per swimmer and if entry deadlines are met
include
a welcome dinner, t-shirt, and swim cap.
Entry Fee: US$ 75.00
= $75.00
Circle one T-shirt size: (only included if entry
is rec’d by 9/30/05) M L XL
Pre-Purchase additional T-Shirts.
Indicate size(s) & amount, US $15 each. This option is only available prior
to 9/30/05:
M____ / L____ /
XL____ Total # of additional T-Shirts ______ x US$15.00 = US$_____
Pre-purchase additional guests
welcome dinners at US$15.00 each. This option is only available prior to
9/30/05. After 9/30/05 if room permits additional tickets may be available at
the door:
Total #
of additional guests: ______
x US$15.00 = US$_____
Total Fees enclosed
= US$ _____
All fees are non-refundable. Incomplete entries will not be
accepted.
Make checks payable in (US$) to Aqua Moon
Adventures and mail with this completed and signed entry form to:
Aqua
Moon Adventures
Questions: www.AquaMoonAdventures.com