Name ___________________________

E-mail ___________________________

_________________________________

Phone ___________________________

Method of Payment:

o     Check (made payable to “Investigation Station”)

o     Credit Card (please complete form)

Credit Card Information (please circle)

Mastercard   Visa    Am Ex    Discover

Name on card _____________________

_________________________________

Credit Card No. ____________________

__________________________________

Expiration Date ________/____________

Security Code ___________

Amount applied to card _____________

Signature __________________________     

RELEASE OF LIABILITY

This release from liability is made and entered into this _____ day of _______________, 2011, by and between “ Bishop McLaughlin Catholic High School and Investigation Station” [hereinafter referred to as the “first party”] and _________________________, [hereinafter referred to as the “participant” (which shall include all agents of the participant).

 The participant freely acknowledges and consents to the following:

1.   The participant is responsible for full and complete insurance coverage of all types on themselves;

2.   The participant understands that there are inherent risks involved in any physical activity and/or exercise;

3.     Prior to participating in this activity the participant has consulted with their health care professional and is in a good state of health to participate in this activity and/or exercise;

4.     The participant is responsible for any injuries received as a result of participating in this activity and/or exercise from either themselves and/or any other participant and/or guest of the event;

5.     The participant agrees to assume any and all risks involved in or arising from the participant’s participation and/or presence at this event, including, but not limited to the risks of injury associated with any physical activity and/or exercise; the unavailability of emergency medical care; and/or negligence and/or deliberate act of another person;

6.     The participant agrees to hold harmless the first party and all successors, assigns, subsidiaries, franchises, affiliates, officers, directors, employees and agents and agrees not to make any claim against them or sue them on account of or in connection with any claim, cause of action, injuries, damages, costs or expenses arising out of participants participation and/or presence at this event;

The participant agrees that the foregoing release of liability is intended to be as broad and inclusive as is permitted by the law in the State of Florida and that in any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

 THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAIVER OF ALL LIABILITY AGREEMENT.

 

______________________________________________________                      
Participant                                                             

______________________________________________________
Telephone number

______________________________________________________

 
______________________________________________________
Address

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Thank you for registering for Investigation Station’s Zumba-Thon, sponsored by San Francis Veterinary Hospital.  Please retain this page for your information.

Date:  Saturday, January 14, 2012

Doors open:  4:30 PM

Time:  5:00 – 7:00 PM

Place:  Bishop McLaughlin Catholic High School
13651 Hays Road
Spring Hill

The school is north of SR 52,  west of the Suncoast Expressway.

Return registration and liability form with payment to:

Investigation Station Zumba-Thon
C/O San Francis 
Veterinary Hospital
18824 County Line Road
Spring Hill , FL 34610

Questions?  

Call:  727-459-7331 or E-mail:  director@investigationstation.net