Lifeline of Ohio  --  Dash for Donation

July 28, 2007

Make check payable to Premier Sports, and mail to:

Premier Sports 401 Charmel Place Columbus, OH  43235

 

Join our "Sea of Green"  --  Help us show the community how many lives are touched through organ and tissue donation! 

 

____  Please check here if you have a direct connection to the cause and would like to request a green race t-shirt as someone whose life has been touched by donation or transplantation.

 

My connection to donation is:

 

___  Donor Family Member

___  Living Donor

___  Transplant Candidate

___  Transplant Recipient

___  Family / Friend

___  Loved one died waiting

 

____  Sorry I cannot attend the Dash for Donation Relay & Run.  I would like to
make a charitable contribution to support Lifeline of Ohio's mission to
promote donation awareness
 

Volunteers

___ I would like more information on volunteering on Saturday, July 22 for
the Dash for Donation.  (you may also call 614-384-7334 to volunteer for
the Dash for Donation)

___  I would like more information on becoming a Lifeline of Ohio Vital
Volunteer.  (you may also call 614-384-7333 for more information)

Event:    1/2 Marathon Run/Walk    1/2 Marathon Relay      5K run/walk    Family Fun Walk    Kids Dash

Email:  ______________________________________________________

Name: _________________________________________      Age: _____         Sex: M / F

Teammate Name (relay): ______________________________  

Address: ________________________________________________________________

City: ______________________ State: _____ Zip: _________ Phone: _________________

T-shirt:    S     M      L      X       XX           Children's Shirt Size:   YS    YM     YL

Lifeline of Ohio Event Waiver and Release

I agree that if I participate in this physical activity, program or event (the "Event") or use any Event facility or Event premises, I do so at my own risk. I agree that I am voluntarily participating in the Event and using Event facilities or premises  and assume all risk of injury, illness, damage or loss to me or my property that might result, including without limitation, any loss or theft of personal property.  I hereby consent to medical treatment in the event of injury, accident and/or illness during the Event.  I agree on behalf of myself (and my personal representatives, heirs, executors, administrators, agents and assigns) to release and discharge Premier Sports, Lifeline of Ohio and all Event sponsors from any and all claims or causes of action (known or unknown) arising out of their negligence. 

 

I acknowledge that I have carefully read this Waiver and Release and fully understand that it is a release of liability.  By my signature below, I am waiving any right that I may have to bring legal action to assert a claim against Lifeline of Ohio and Premier Sports and all Event sponsors for their negligence. 

 

 

____________________________________________________________________________________________

Signature of Entrant (or parent/guardian if under 18 years of age)                                   Date