2015 Plaza de la Raza Zumbathon Registration Form.
Plaza de la Raza Child Development Services 2015 Zumbathon Registration Form One registration form is required per participant. Last Name _______________________________First Name________________________________ Address_____________________________________________________________________________ City___________________________________________________State_____________Zip_________ Phone__________________________________Email_______________________________________ DOB______/______/________Gender___________________________________________________ (Note: Date of birth and gender are optional) Emergency Contact Name____________________________ Phone_______________________ T-Shirts will be provided to pre-registered participants. Those registering on the event day will receive shirts on a first-come first-served basis. Available sizes are: ADULT: S M L XL (Circle One) Payment ___Enclosed is my cash or money order for $_________ payable to Plaza de la Raza Child Development Services, Inc. Waiver and Release: I declare that I am participating in the 2015 Plaza de la Raza Zumbathon, having voluntarily and knowingly assumed ALL RISKS involved in this Special Event, including but not limited to those further described in this Waiver. The immediate physical risks and hazards associated with normal, vigorous physical activity include (but are not limited to) physical discomfort, fatigue, muscular soreness, falls, pulled or strained muscles, overuse injuries, heat stress, and the rare instance of abnormal responses of the cardio-respiratory system, including heart arrhythmia, heart attack, stroke, and sudden death. In consideration for allowing my participation in this Special Event and intending to be legally bound thereby, I hereby for myself, my heirs, executors, administrators and assigns, attorneys and representatives, WAIVE AND RELEASE any and all rights and claims for negligence, injuries, physical or financial damages or losses that I may incur against all participating agencies involved in the above stated Special Event, and specifically Plaza de la Raza Child Development Services, El Rancho Unified School District, and their respective employees, agents, representatives and attorneys, successors and assigns, regarding any and all activities connected with my participation in the Special Event . Plaza de la Raza Child Development Services 2015 Zumbathon Registration Form I also WAIVE any and all rights or benefits under California’s Workers’ Compensation laws for any injury incurred as a result of my participation in this event. In addition, I waive any and all rights or benefits which I may have under section 1542 of the California Civil Code, which reads: A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have materially affected his or her settlement with the debtor. Signature__________________________________________ Date ___________________________ For questions please contact us at zumba@pdlr.org Send your completed registration form and payment by April 20, 2015 to: Plaza de la Raza Child Development Services Attn: Zumba Event 8337 Telegraph Rd., Ste. 300 Pico Rivera, CA 90660
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