The Victor

St. Croix 5 Mile Coral Reef Swim

Sunday, October 28th, 2001

Entry Form

 

All swimmers must complete this form and sign the Liability Release. If part of a team all members must individually complete and sign the release and mail them together. $75.00 entry fee is per swimmer ( i.e. the 3 person relay = $225.00 total). Fee includes Welcome Dinner, Award Barbecue, T-shirt and swim cap.

 

Name:________________________________ Sex:   _____Male  ____Female  DOB:_____ Age:________

                 last,                        first                                                                                                       on race day

Address_____________________________________________________________.

                 Street                     City                      State                             Zip Code

Daytime phone:_____________________. Evening phone:_____________________.

E-Mail____________________________.

 

Circle Division and Event Category:                                         

Open Division                                                                                      Junior Division  

Solo Swimmer             M  F                                                            Solo Swimmer             M    F     

Solo w/Fins                 M F

3 Person Team*          MIXED                                                     

*Team Name:___________________________________________________________________.

*Other Team Members besides yourself: (1). ___________________(2)._____________________.

                                                                                                         

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 I am aware of all  the risks inherent in open water swimming and agree to assume those 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 each swimmer is $75.00                                                                                                   =____________.

Entry Fee St Croix Residents Junior Division only (Dinner not included) is $35                     =____________.

Swimmers T-Shirt (included): M_______L______XL________

Additional T-shirts (size & amount): M_____  L_______ XL_____              ____ x $15.00 =____________.

Additional guests Welcome Dinner are $20.00 each.                         guests:   _____x $20.00 =____________.

Additional guests Awards Barbecue are $15.00 each                        guests:   _____x $15.00 =____________.

Total Entry Fees enclosed                                                                                                                 $___________.

All fees are non-refundable

 

Make checks payable to Aqua Moon Adventures and mail with your entry to: Aqua Moon Adventures P. O. Box 9448 Coral Springs, Florida 33075