St. Croix Coral Reef Swim

October 24^th 2004

9^th Annual St Croix 5-Mile Coral Reef Swim

ENTRY FORM

You may print this form or Register online by clicking here.

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. US$80.00 entry fee is per swimmer (i.e. the 3 person relay = US$240.00 total). Fee includes: Award Barbecue, t-shirt and swim cap. By entering you acknowledge you have read the event information, agree to the AUTHORIZATION AND EVENT PROMOTION and LIABILITY RELEASE.

Name:

Last, First, MI

Sex: Male Female Date of Birth: / / Age on race day:

Address:

Street Apt / Suite #

City State/Province Zip

Country

Daytime phone Evening phone

E-Mail Address

Contact location while on St Croix

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 Last Name, First #2 Last Name, First

St. Croix Coral Reef Swims, Entry Form, continued (please include all pages of form with entry)

Last Name

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.

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, VOLUNTEERS, AS WELL AS THE RESPECTIVE OFFICERS, DIRECTORS, AGENTS AND EMPLOYEES OF ALL OF THE FOREGOING ENTITIES 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. 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 The Buccaneer, Inc., 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 read this entire Liability Release and understand its content without exception.

Applicant’s Signature: __________________________________________________________________

Parent's Signature: __________________________________________________________________

(required for swimmers age 18 and under)

St. Croix Coral Reef Swims, Entry Form, continued (include all pages of form with entry)

Sunday, October 24th 2004

Last Name

Entry Fee is US$ 80.00 = US$_________

Swimmers T-Shirt, circle one (included with entry fee): M / L / XL

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 Awards’ Barbecue are US$20.00 each.

Total # of additional Barbecue guests: ______ x $US20.00 = US$____________

Total Fees enclosed (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