St. Croix Coral Reef Swims
October 23rd – October 27th
2002
7th Annual St Croix 5-Mile
Coral Reef Swim - October 27th 2002
All
swimmers must complete this form and sign the Liability Release. If part of a team (only offered in the
5-mile swim), all members must individually complete and sign the release and mail
them together. US$90.00 entry fee is per swimmer (i.e. the 3 person relay =
US$270.00 total). Fee includes Welcome Dinner, Award Barbecue (5-mile swim
only), T-shirt and swim cap. By
entering you acknowledge you have read the event information. Remember, if
entering both the 5 and 10-mile swims, to send separate checks for each event.
Name: ______________________________ ______________________ Sex: ___Male
___Female
Last, First
DOB: ___/___/___ Age on race day:________
Address:__________________________________ _____________________ _______________
Street, City State, Zip Code Country
Daytime
phone: ________________ Evening phone: _________________
E-Mail: ____________________________
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Check/Circle Division and Event Category:
( ) 5-Mile
Open Division
( ) 5-Mile Junior Division (18 and younger)
Solo Swimmer M /
F
Solo Swimmer w/Fins M /
F
3 Person Team MIXED (only one category for teams, includes same
sex or any combination m/f)
Team Name: ___________________________________________________________________.
Other two Team Members: (1)
___________________ (2)_____________________
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( ) 10-Mile Buccaneer-to-Buck & Back Open
Division
Solo Swimmer M /
F
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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 BUCCANEER,
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)
7th Annual St Croix 5-Mile Coral Reef Swim
Sunday,
October 27th 2002
5-Mile Open and Junior Division (Solo, Solo
w/fins, or Member of 3 Person Team)
Entry Fee US$90.00 =
US$90.00 ______________
5-Mile Junior Division for St. Croix Residents
(Dinner not included)
Entry Fee US$45.00 =
US$45.00 ______________
Swimmers T-Shirt (circle one - included w/
5-mile swim entry): M /
L / XL
Additional T-shirts (indicate below quantity
for each size requested):
M_____ L_____ XL_____ Total Additional T-shirts ____ x US$15.00 = ______________
Additional guests for Welcome Dinner are
US$27.00 each
Total
Additional Dinner guests ____ x
US$27.00 = ______________
Additional guests for Awards’ Barbecue are
US$20.00 each
Total
Additional Barbecue guests ____ x
US$20.00 = ______________
Total Entry Fees 5-Mile
Swim enclosed (separate check) US$ ____________
1st
Annual 10-Mile Buccaneer-to-Buck & Back
Thursday, October
24th 2002
10-Mile Open Division
Entry Fee US$90.00 =
US$90.00 ______________
Swimmers T-Shirt (circle one - included w/
10-mile swim entry): M /
L / XL
Additional T-shirts (indicate below quantity
for each size requested):
M_____ L_____ XL_____ Total Additional T-shirts ____ x US$15.00 = ______________
Additional guests for Welcome Dinner are
US$27.00 each
Total
Additional Dinner guests ____ x
US$27.00 = ______________
Total Entry Fees 10-Mile
Swim enclosed (separate check) US$
____________
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