First Name:

                   Age:

             Gender: Select One Male Female

           Address:

                  City:

                State:

                    Zip:

               Phone:

  Date Of Birth:

                 Shirt: Select One No Shirt Small Mediium Large X Large XX Large

Partners Name: For Participants registering as Twosomes.

Waiver of Liability: I, intending to be legally bound, for myself, my heirs, next of kin, executors, and administrators, voluntarily assume all risks of accident or injury and release and forever discharge, indemnify and hold harmless the Great Miami Valley YMCA, YMCA Middletown Street Striders, Atrium Medical Center, the city of Middletown, officers, sponsors, and agents (collectively the "Released Parties"), from any and all liability for personal injury or property damage of any kind sustained during the YMCA Street Striders 2010 Sweetheart Shuffle, whether such personal injury or property damage is caused by the gross negligence or carelessness of the Released Parties. I have full knowledge of the risks involved and attest that I am physically fit and sufficiently trained to participate in the Athletic Event. I grant permission to all foregoing to use any photographs, motion pictures, recordings or any other record of this event for any legal purpose. NO BABY STROLLERS, ROLLERBLADES, SKATES, DOGS, OR HEADPHONES.

              Waiver: Select Yes

          Signature:
(Parent's signature is required if Sweetheart Shuffle participant is under 18 years of age)
 

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