General 1 — Shalom Macon

Thank You!

Thank you for registering to participate in Shalom Macon’s inaugural 5K Fun Run / Walk on Sunday October 20, 2024! Please take a moment to fill out the waiver below for all participants in your family.

Participant's Name

First Name

Last Name

Birthday

MM

DD

YYYY

Age

Parent / Guardian Information (If Applicable)

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Medical Information

Insurance Company

Policy # / Group #

Primary Doctor's Name & Phone

List any medical allergies, conditions, medications, or medical concerns:

Signature

I understand all reasonable safety precautions will be taken by SHALOM MACON and its agents during events, trips, and activities. I also understand the possibility of unforeseen hazards and know the inherent possibility of risk. I hereby agree to release and forever discharge, and agree to hold harmless, SHALOM MACON, its leaders, employees, volunteer staff from any liability, and claims for damages, losses, sickness, or injuries. I understand that if medical attention is needed, for this individual during this activity, every attempt will be made to consult the listed contact person on this form. If, however, the persons listed cannot be reached, I give my permission to the activity leaders to secure the services of a licensed physician or surgeon to provide medical services deemed necessary for the well-being of the individual.

Date of Signature

MM

DD

YYYY