Hospital Days Triathlon Individual Registration Form

Click here to download the individual registration form. You may complete these forms and mail them with your payment to Hospital Days Triathlon, New London Hospital.

 

Required fields are marked with an asterisk *.

*Age Categories:

Under 18

18-29

30-39

40-49

50-59

60+

*Swimmer Level:


Individual Registration:

*First Name:

*Last Name:

Gender:

*Date of Birth:

/ /

*e-mail:

*Address 1:

Address 2:

*City:

*State:

*Zip:

*Day Phone:

( ) - x

T-Shirt Size:

Note: If you register after June 14, we cannot guarantee your requested t-shirt size will be available on race day.

Acknowledgment and Release

I acknowledge that a triathlon is an extreme test of a person's physical and mental limits and carries with it the potential for death, serious injury and property loss. I HEREBY ASSUME THE RISKS OF PARTICIPATION IN THIS TRIATHLON. I certify that I am physically fit, have sufficiently trained for participation in this event(s) and have not been advised otherwise by a qualified medical person. I WAIVE, RELEASE AND DISCHARGE from any and all claims or liabilities for death, personal injury, property damage, theft or damages of any kind which arise out of or relate to my participation in or my traveling to and from this event THE FOLLOWING PERSONS OR ENTITIES: New London Hospital, New London Historical Society, event sponsors, race directors, volunteers, all states, cities, counties or localities in which events or segments of events are held, and the officers, directors, employees, representatives of any of the above. I AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein and to INDEMNIFY AND HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions during this event. I hereby affirm that I am 18 years or older, I have read this document, and I understand its contents.

*Individual acceptance of liability:

Parent/Guardian acceptance of liability:

If the participant is under 18 years of age, a parent or guardian must execute, in addition to the foregoing release, the following, for and on behalf of the minor.

The undersigned, the parent and natural guardian of , hereby executes the foregoing release for and on behalf of the minor named herein. As the natural and legal guardian of such minor, I hereby bind myself, the minor and our executors, administrators, heirs, next of kin, successors and assigns to the terms of the foregoing release. I represent that I have the legal capacity and authority to act on behalf of the minor named herein, and I agree to indemnify and hold harmless the persons or entities mentioned in the foregoing release for any claims made or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the foregoing release or in the execution of this consent.

I hereby authorize any licensed physician, emergency medical technician, hospital or other medical care facility ("medical provider") to treat the minor named herein for the purpose of attempting to treat or relieve any injuries received by said minor arising out of or relating to this event. I authorize any such medical provider to perform all procedures deemed medically advisable in attempting to treat or relieve any such injuries. I consent to administration of anesthesia as deemed advisable during the course of such treatment. I realize and appreciate that there is a possibility of complications of unforeseen consequences in any medical treatment, and I assume any such risk for and on behalf of myself and said minor. I acknowledge that no warranty is being made as to the results of any medical treatment. NOTE: Parent/guardian must also sign release above.

Parent/Guardian accepts above statement:

Relationship to Minor:

Payment Information:

*Credit Card Type:

*Credit Card Number:

*Credit Card Expiration:

/

*Security Code:

Fee:

$65.00

I would like to make an additional donation:

Additional Amount:

Other Amount ($):

Note: Registration Fees are Non Refundable

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