Stirling Family Memorial Ranch Rodeo

And 5K Race and Fun Walk

Saturday, September 20, 2014
Ft. Pierre, Stanley Co. Fairgrounds
Entry Form

Last Name First Name

E-mail Address

Mailing Address

City State Zip

Phone Age Date of Birth Gender

Registration Fee $35 $___
Children 12 and under $10 $___
Cancer Survivor Registration Free! ___
I would like to donate $___
TOTAL $___

I would like to be recognized as a cancer survivor

T-shirt size S M L XL 2XL 3XL
YXS YS YM YL YXL (Youth Sizes)

Prize Information:
For the past 16 years, the goal of the Stirling Family Memorial Ranch Rodeo has been to raise money for LOCAL cancer
victims. Over $25,000 has been paid out to 100+ families dealing with this disease. This year we are excited to include a
5K Run and 1 mile Fun Walk to this endeavor.

There will be a womens category and a mens category for the 5K Race. The winner with the fastest time for each
category will receive a check to be paid to his/her loved one dealing with cancer. Along with the Ranch Rodeo
participants, all runners and walkers will be able to put a name of a loved one with cancer into a drawing. The name
drawn will receive a check to aid as they deal with their disease.

Payment Information
Please make check or money order payable to:
Stirling Family Memorial Ranch Rodeo

Entry form MUST be signed below!

Mail Completed
form by
September 3
rd
to:

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND
INDEMNITY AGREEMENT AND CONSENT TO MEDICAL TREATMENT
By my signature below, I acknowledge that I am aware of, appreciate the character of, and voluntarily assume the risks involved in participating in The Stirling Family
Memorial 5k Race and Fun Walk. By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal representatives, and
agents, I hereby:
1. Waive any claim or cause of action against and release from liability The Stirling Family Memorial 5k Race and Fun Walk, its organizers, volunteers, and agents for
any liability for injuries to person or property resulting from my participation in the activity listed above;
2. Agree to indemnify and hold harmless The Stirling Family Memorial 5k Race and Fun Walk, its organizers, volunteers, and agents for any claims, causes of action,
or liability to any other person arising from my participation in the activity listed above; and
3. Consent to receive any medical treatment deemed advisable during participation in the activity listed above.
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF THE RISK AND INDEMNITY AGREEMENT AND CONSENT TO
MEDICAL TREATMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND
HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND
MY SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.
__________________________________________________________________________________________________________________________________________________________________________________
Signature (Signature of Parent or Legal Guardian if Participant is under 18 years of age is required) Date
LaCosta Jackson
29712 270
th
Ave
Crookston, NE 69212

For additional Ranch Rodeo information, please
visit: www.StirlingFamilyRanchRodeo.com