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PARTICIPANT WAIVER AND RELEASE FOR MINORS

(THIS MUST BE COMPLETED IN FULL FOR THE MINOR TO ENTER THE RACE)

has my (our) permission to participate in


Name of Minor
Turlock Chaplaincy, Inc., 6th annual one-mile, 5K & 10K fun run on April 8, 2017, in Turlock, California
beginning at 850 E. Main Street, Turlock, California, at approximately 9:00 a.m. to approximately 12:00
p.m.

I understand and acknowledge that a running/walking event poses risks to my child, including the risk of
physical or emotional injury or damage, including serious injury or death to my child, to property, or to
third parties.
I (we), as parent(s) or guardian(s) of the minor, do hereby, for my child, myself, my heirs, executors and
administrators, release and forever discharge Turlock Chaplaincy, Inc., a California non-profit
corporation, and all officers, directors, employees, agents and volunteers of the organization, acting
officially or otherwise, from any and all claims, demands, actions or causes of action which in any way
arise from the minors participation in the above noted event, including pre- and post-race activities. I
also grant Turlock Chaplaincy, Inc. the right to use any images of my child taken at the race.
I hereby certify that the minor is my son / daughter (circle one) and that his/her date of birth is
and I do hereby certify that to the best of my knowledge and belief said minor is in good health. In case of
illness or accident, permission is granted for emergency treatment to be administered. It is further
understood that the undersigned will assume full responsibility for any such action, including payment of
costs.

I agree and understand the terms of this document apply to my child(ren) and I certify that I am the parent
or legal guardian of the participants listed below, with the legal authority to sign on their behalf.

I hereby advise that the above named minor has the following allergies, medicine reactions or unusual
physical conditions, which should be made known to a treating physician: (If none, please write the word
none.):

1.
Signature Print Name

2.
Signature Print Name

Address City State Zip Phone (incl area code)

Alternate Adult:

Signature Print Name

Address City State Zip Phone (inc area code)

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