Ticker Tester Entry Form
Sept 16. 2000 9:30am

Please Fill out form, print and submit to :

Ticker Tester
Lethbridge Regional Hospital Foundation
960-19 St.S. Lethbridge, AB
T1J 1W5

Name(in full)

Gender:

Male
Female

Address:

Category:

5Km Walk/Run
10Km Run

City:

Postal Code:

Phone#:

Age Categories (as of Race Day):

T-Shirt Size

10& Under
11-14
15-19
20-29

30-39
40-49
50-59
60+

S
L

M
XL
Tshirt Only No Race Number
Instead of Tshirt, I will donate the cost of the Tshirt to Cardiac Rehab


Please Read & Sign Waiver

In consideration of your acceptance of this race, I, for myself, my heirs, executors, administrators and assigns, forever waive, release and discharge any and all rights, demands, claims for damages and causes of suit or action known or unknown, that I may have against the Lethbridge Regional Hospital and any and all participating race sponsors and directors, officers, agents, and employees of such parties, for any and all injuries in any manner arising or resulting from my participating in said race. I attest
and verify that I have full knowledge of the risks involved in this race, that I assume those risks, that I will assume and pay my own medical and emergency expenses in the event of an accident, illness or other capacity, regardless of whether I have authorized such expenses and that I am physically fit and sufficiently trained to participate in this race.

Signature:______________________________________________

Parent/Guardian Signature (if under 18):______________________________________

ALL PROCEEDS GO TO THE CHR CARDIAC REHABILITATION PROGRAM