Potomac Swim Entry Form - June 2, 2012 - WAIT-LISTING ONLY
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1. Default Section

1. Name

Name

2. Address, city, state & zip code

Address, city, state & zip code

3. Age on date of swim June 2, 2012:

Age on date of swim June 2, 2012:

4. Cellphone

Cellphone

5. Daytime phone

Daytime phone

6. Evening phone

Evening phone

7. Email address

Email address

8. Medical/other information to declare

Medical/other information to declare

9. Open Water Experience

Open Water Experience

10. WAIVER AND AGREEMENT
As a condition of being accepted in the June 2, 2012, Potomac River swim, I agree to make timely payment of the $75 registration fee and raise the minimum amount of pledge money ($250) before the event; to attend the required June 1, 2012 pre-swim meeting; to adequately train for the swim; to abide by event rules and regulations including water safety determinations that may result in my removal from the water if deemed to be in danger; to accept medical treatment deemed necessary during the event; and to hold harmless by acknowledging and assuming the risks involved in an endurance activity of this nature and for myself and heirs waive all claims for damages or injury arising during the event against any individual, group, association, agency or government body involved with this activity's organization, conduct, and/or support.
CONFIRM "OK" & ADD DATE:

WAIVER AND AGREEMENT As a condition of being accepted in the June 2, 2012, Potomac River swim, I agree to make timely payment of the $75 registration fee and raise the minimum amount of pledge money ($250) before the event; to attend the required June 1, 2012 pre-swim meeting; to adequately train for the swim; to abide by event rules and regulations including water safety determinations that may result in my removal from the water if deemed to be in danger; to accept medical treatment deemed necessary during the event; and to hold harmless by acknowledging and assuming the risks involved in an endurance activity of this nature and for myself and heirs waive all claims for damages or injury arising during the event against any individual, group, association, agency or government body involved with this activity's organization, conduct, and/or support. CONFIRM "OK" & ADD DATE:

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