5K Run/Walk: 6 & Under WALK/RUN - Registration

Event Date*
First Name*
Last Name*
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Address*
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Address 2
City*
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State*
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Zip Code*
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Email Address*
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Phone*
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Alt Phone
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Gender

Male Female
Cancer Survivor

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T-Shirt Size*
Age
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HOLD HARMLESS AND WAIVER OF LIABILITY
The person registered agrees to assume responsibility for and further agree to indemnify, defend and to hold Thibodaux Regional Health System, its agents, officers and employees harmless from any loss or liability for or an account of injury to (including death of) persons or damage to property, including costs, attorney fees and expenses incidental, thereto, arising from participation in the “5K Run/Walk: 6 & Under WALK/RUN, ” whether or not said losses, injuries, deaths or property damages arise partially or wholly from the fault of Thibodaux Regional Medical Center, its agents, officers and employees.

I understand that in the event I or my child is injured while participating in the aforementioned activity, I am responsible for any and all medical bills and expenses that may arise from said injury. If my child is participating and I am not present at the event, I give my permission to send my child to the nearest emergency department for treatment. This may include ambulance transportation if necessary.

Event may include photo and/or video recording with or without audio. I hereby grant permission to the rights of my image, likeness, and sound of my voice as recorded on audio or video tape without payment or any other consideration.

I agree

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