ADIRONDACK CHALLENGE FLATWATER CANOE RACE SUNDAY JULY 21, 2013
Pre registration required by July 15, 2013
Make checks payable to: Adirondack Watershed Alliance - mail completed form to: PO Box 66 Lake Clear, NY 12945
Paddler 1: Paddler 2:
Name: __________________________________ Name: _____________________________________
Address: ________________________________ Address: ___________________________________
________________________________________ ___________________________________________
Home phone: ___________________Age: ____ Home phone: _______________ Age: ___________
Email Address: ____________________________ Email Address: ______________________________
ARE YOU A MEMBER OF AWA? YES NO ARE YOU A MEMBER OF AWA? YES NO
Paddler 3: Paddler 4:
Name: __________________________________ Name: _____________________________________
Address: _________________________________ Address: ___________________________________
_________________________________________ ___________________________________________
Home phone: ___________________Age: _____ Home phone: _______________ Age: __________
Email Address: _____________________________ Email Address: ______________________________
ARE YOU A MEMBER OF AWA? YES NO ARE YOU A MEMBER OF AWA? YES NO
C-4 Pro-Class Teams please indicate category:
MIXED MEN WOMEN SENIOR
Amateur Teams please indicate class and category: _______________ _________________
Participant Waiver and Release
I acknowledge and agree that there are inherent dangers in the sport of canoe and kayak racing. As evidenced by my signature below I represent and agree that I am in appropriate physical condition to participate and accept all risks and consequences of my participation. I agree to hold harmless the organizers, sponsors, land owners, municipalities, New York State, the New York State Urban Development Corporation, d/b/a Empire State Development, the New York State Department of Economic Development and any other person or entity involved in the event against any liability for any injury incurred by me and/or my minor child while participating in this activity. I further give my permission for my name and photograph (and the name and photograph of my minor child) to be used for educational and promotional purposes related to paddle sports, the Adirondack Watershed Alliance and promotion of tourism and water sports in New York State. Furthermore, I release any and all royalties, copyright and any other rights (including but not limited to any privacy rights under Article 5 of the Civil Rights Law.)
Paddler 1 Signature ____________________________ Paddler 2 Signature___________________________
Parent Signature ________________________________ Parent Signature______________________________
Paddler 3 Signature ____________________________ Paddler 4 Signature___________________________
Parent Signature ________________________________ Parent Signature_______________________________
(Parent signature required if entrant is under 18 years old)
Pre registration required by July 15, 2013
Make checks payable to: Adirondack Watershed Alliance - mail completed form to: PO Box 66 Lake Clear, NY 12945
Paddler 1: Paddler 2:
Name: __________________________________ Name: _____________________________________
Address: ________________________________ Address: ___________________________________
________________________________________ ___________________________________________
Home phone: ___________________Age: ____ Home phone: _______________ Age: ___________
Email Address: ____________________________ Email Address: ______________________________
ARE YOU A MEMBER OF AWA? YES NO ARE YOU A MEMBER OF AWA? YES NO
Paddler 3: Paddler 4:
Name: __________________________________ Name: _____________________________________
Address: _________________________________ Address: ___________________________________
_________________________________________ ___________________________________________
Home phone: ___________________Age: _____ Home phone: _______________ Age: __________
Email Address: _____________________________ Email Address: ______________________________
ARE YOU A MEMBER OF AWA? YES NO ARE YOU A MEMBER OF AWA? YES NO
C-4 Pro-Class Teams please indicate category:
MIXED MEN WOMEN SENIOR
Amateur Teams please indicate class and category: _______________ _________________
Participant Waiver and Release
I acknowledge and agree that there are inherent dangers in the sport of canoe and kayak racing. As evidenced by my signature below I represent and agree that I am in appropriate physical condition to participate and accept all risks and consequences of my participation. I agree to hold harmless the organizers, sponsors, land owners, municipalities, New York State, the New York State Urban Development Corporation, d/b/a Empire State Development, the New York State Department of Economic Development and any other person or entity involved in the event against any liability for any injury incurred by me and/or my minor child while participating in this activity. I further give my permission for my name and photograph (and the name and photograph of my minor child) to be used for educational and promotional purposes related to paddle sports, the Adirondack Watershed Alliance and promotion of tourism and water sports in New York State. Furthermore, I release any and all royalties, copyright and any other rights (including but not limited to any privacy rights under Article 5 of the Civil Rights Law.)
Paddler 1 Signature ____________________________ Paddler 2 Signature___________________________
Parent Signature ________________________________ Parent Signature______________________________
Paddler 3 Signature ____________________________ Paddler 4 Signature___________________________
Parent Signature ________________________________ Parent Signature_______________________________
(Parent signature required if entrant is under 18 years old)
