Registration Form

 

5th Annual Narcolepsy Bed Race

Saturday March 11, 2017

Judging from 11:30 AM, Race Starts at 12:00 PM

To be held at Covenant Presbyterian Church

1831 Deyerle Road

Roanoke, VA 24018

 

Entry Fee: $50 per team

Make checks payable to ‘Narcolepsy Network’

Entry fee may be tax-deductible

 

Return Entry Form With Payment To:

Mark Patterson

6021 Trinity Court

Roanoke, VA 24018

Or by email at narcolepsybedrace@gmail.com

 

 

Team Name: __________________________________________________

 

Team Captain/Contact: __________________________________________

 

Address: ______________________________________________________

 

City: _______________________ State: _______________ Zip: _________

 

Phone Number(s): ______________________________________________

 

Email Address: ________________________________________________

 

 

All registration forms and waivers must be submitted by

Thursday March 9, 2016 

All monies must be received by

Friday March 10, 2016

Waiver of Liability

Narcolepsy Bed Race benefiting Narcolepsy Network, Inc.

I know that running in a bed race is a potentially hazardous activity. I should not enter and run unless I am medically and physically able. I also know that there may be some hazards on the racecourse. I also assume any and all other risks associated with running in this event and participating in all other activities scheduled including but not limited to falls, contact with other participants, spectators or equipment, the effects of the weather, including cold temperatures or precipitation, and the condition of the roads, all such risks being known and appreciated by me. In consideration of your permitting me to participate in the Narcolepsy Bed Race on March 11, 2017, I hereby for myself, my heirs, executors, administrator or anyone else who might claim on my behalf, covenant not to sue, and waive, release and discharge Narcolepsy Network, its members, volunteers, race officials and any sponsoring body, their successors and assigns, and Covenant Presbyterian Church and all of their officials and employees from any and all claims or cause of action I may have for all personal injuries or property damages caused by or arising out of the Narcolepsy Bed Race and its related activities. I also agree to abide within the rules and regulations issued by race officials.

Indemnity and Release for Radio, Television, Internet and Print Media

For sufficient consideration and the right to appear, I agree to protect and indemnify Narcolepsy Network, its officers, members and volunteers, and advertising agency, and their respective officers and employees and to hold it and them harmless from and against all liability, loss, damages, expenses, judgments, counsel fees, costs and other charges, against it or them or for which it or they shall become liable by virtue of or arising out of our caused by an matter or materials supplied or spoken by me in a telecast of the Narcolepsy Bed Race. I hereby give my permission for the Narcolepsy Bed Race to use my picture and/or name in any publicity, deemed necessary for the promotion of this event at no compensation.

A Parent or guardian MUST sign for any member under 18 years of age.

Team Captain:

              DOB:

       Signature:

Team Member:

               DOB:

        Signature:

Team Member:

               DOB:

        Shirt Size:

        Signature:

Team Member:

               DOB:

        Signature:

Team Member:

               DOB:

        Signature:

Download the Registration form and return to narcolepsybedrace@gmail.com no later than March 9, 2017, or print the form below. Bedrace entry form 2015_distributed.pdf