Bonkers for Burpees Registration Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP Code Email* Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Waiver & Release of Liability*In consideration of participation in the BONKERS for BURPEES AMP Games, I represent that I understand the nature of the AMP Games and that I and/or my minor child am qualified, in good health, and in proper physical condition to participate in such Activity. I acknowledge that if I and/or my minor child believe event conditions are unsafe, I and/or my minor child will immediately discontinue participation in the Activity. I fully understand that the AMP Games may involve risk of serious bodily injury, including permanent disability, paralysis and death, which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the "releasees" named below; and that there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks and all responsibility for losses, costs, damages I and/or my minor child incur as a result of my and/or my minor child’s participation in the Activity. I hereby release, discharge, covenant not to sue Special Olympics Inc., Special Olympics Ohio, AMP Fitness LLC, its respective administrators, directors, agents, officers, volunteers, employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises on which the activity takes place, (each one considered on the "RELEASEES" herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the "releasees" or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk, I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the releasees from any loss, liability, damage, or cost which any may incur as the result of such claim. I have read this release and waiver of liability, assumption of risk and indemnity agreement, and parental consent agreement and understand that I have given up substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force effect. I also hereby consent to and permit emergency treatment in the event of illness or injury. I also grant you permission to use my name, picture, voice and words in television, radio, films, newspaper, magazines, and other media, and in any other form not heretofore described for the purpose of advertising and fund raising advertising and fund raising activities to support Special Olympics Ohio, Inc. I am at least 18 years of age. Yes, I have read and agree to the terms of the waiver. Team members under age 18 are required to submit a waiver also read and acknowledged by a parent or guardian.Name of Parent or Guardian* First Last Acknowledgement by Parent or Guardian* Yes, I have read and agree to the terms of the waiver. PhoneThis field is for validation purposes and should be left unchanged.