HERSHEY’S 3rd
ANNUAL BUTT BUST-N BIATHLON
Registration Form
Saturday August 26th
Last
name________________________
First name____________________
Street
address_____________________________
City____________________
State/Zip_______________Home
Phone________________
E-mail___________________
_____Male
_____Female
Age On Race Day____________
Date of
Birth___________________
Individual____________
Team________________
Team
members_______________________________________
T-shirt
size (circle one) 2X
X-large large
medium small
Entry
Fee $_______$25 individual
$35 team $5 child Add
$5 late entry
ALL
ATHLETES MUST READ AND
SIGN. PLEASE READ CAREFULLY
BEFORE SIGNING
ACKNOWLEDGEMENT, WAIVER, AND
RELEASE FROM LIABILITY.
All
acknowledge that a Biathlon
is a major test of a
person’s physical and mental
limits and carries the
potential of death, serious
injury, and property loss.
I HEREBY ASSUME THE RISKS OF
PARTICIPATION in the
“Hershey Butt Bust-N
Biathlon”. I certify that I
am physically fit, have
sufficiently trained for
this event, and have not
been advised otherwise by a
qualified medical person. My
signature acknowledges that
I hereby take the following
action for myself, my
executors, administrators,
heirs, next of kin,
successors, and assigns: (a)
I agree to abide by the
rules of the competition (b)
I waive, arise out of or
relate to my participation
in or my traveling to and
from this event, the
following persons or
liabilities for death,
personal injury, property
damages of any kind which
arise out of or relate to my
participation in or my
traveling to and from this
event, the following persons
or entities: Hershey Lion’s
Club, Mitch Huebner,
employees, event sponsors,
race directors, event
producers, volunteers, all
states, cities, counties or
localities in which the
event segments are held, and
the officers, directors,
employees, representatives,
agents, and family members
of any of the above, (c) I
agree not to sue any of the
persons or entities
mentioned above for any of
the claims or liabilities
that I have waived, released
or discharged herein; and
(d) I indemnify and hold
harmless the persons or
entities mentioned above
from any claims made or
liabilities assessed against
them as a result of my
actions during this event.
I
HEREBY AFFIRM THAT I AM
EIGHTEEN (18) YEARS OF AGE
OR OLDER, I HAVE READ THIS
DOCUMENT AND UNDERSTAND ITS
CONTENTS.
Please
print
name__________________________________Date__________________
Signature: (For persons
under the age of eighteen
(18), a parent or guardian
must sign)
__________________________________________
Biathlon
2242 S. Crane View Rd.
North Platte, NE 69101
Contact
Person: Mitch Huebner
308-520-0576. 308-532-1940
mhuebner@hamilton.net
