Cardboard Cup Registration Thank you for your interest in Cornerstone Youth Center's 1st Annual Cardboard Cup!Please fill out the form below completely.See you August 16th, 2014! Question Title * 1. Participant # 1 Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 2. Participant #2 Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 3. Age Category For Race 6-10 years old @ 1pm 10-18 year old @ 1:30pm Adults 18+ @ 2:00pm All Ages @ 2:30pm Question Title * 4. Does Participant #1 know how to swim and will they have their own life vest. Yes No Other (please specify) Question Title * 5. Does Participant #2 know how to swim and will they have their own life vest. Yes No Other (please specify) Question Title * 6. Do you understand the Build Rules for the Cardboard Cup?Design and build a boat to complete a short pond course manually propelled by two people. Paddles can be made out of any material.The entire boat must be constructed using corrugated cardboard, duct tape, glue and single part paint. No water sealant paint. All materials except cardboard, duct tape, glue and decorative paint are illegal. Examples of said materials include, fiberglass, wood, rubber, shrink wrap, caulking, epoxies and waterproof sealants. Crew members must be able to swim to participate and also provide their own life jacket. Please be prepared to go down with your shipNo pushing or poling off the bottom of the pond to propel your boatSwashbucklers found guilty of illegal boat materials will be subject to punishment. Please adhere to boat rulesNOT ADHERING TO THESE RULES WILL BE CAUSE FOR DISQUALIFICATION. Yes No Other (please specify) Question Title * 7. Will you be participating in the Best Overall Theme contest? Yes No Question Title * 8. Do you plan to pay the $10.00 per team entry fee on August 16th, 2014. Sign In/Registration begins at 12pm by the Monroeville Pond Yes No Other (please specify) Question Title * 9. RELEASE AND WAIVER OF ANY AND ALL CLAIMS AS A RESULT OF PARTICIPATION IN ACTIVITIES OR SUPPORT COUNSELING OR INJURIES OR PROPERTY LOSS OR DEATH: The undersigned hereby attests and acknowledges that he/she is entering upon property owned and or leased by The Southeast Youth Council, Inc and or Monroeville Park Board. with full knowledge of the potential risks, dangers and possibility of injury that may arise out of operation and activities of The Southeast Youth Council, Inc. I/we further acknowledge that The Southeast Youth Council, Inc., its employed staff, its volunteer staff, its officers and/or it directors may offer several forms of support counseling or activities which may result in injury or loss of property. I/we agree that The Southeast Youth Council, Inc. will not be held responsible for those injuries or property losses incurred while engaged in activities and/or support counseling offered. I/we further agree to indemnify and hold The Southeast Youth Council, Inc., its employed staff, its volunteer staff, its officers and or its director harmless from any and all liability including claims asserted by third parties for any care rendered to the undersigned.PLEASE TYPE FULL NAME & DATE Question Title * 10. RELEASE AND MEDICAL AUTHORIZATION: In the event of an emergency, if the parents/guardians or emergency contacts cannot be reached, I hereby give permission to transport myself or my child to a hospital for emergency medical or surgical treatment, and I agree to accept any and all financial responsibility for such treatment. I wish to be advised prior to treatment by the hospital or doctor, if possible.PLEASE TYPE NAME & DATE Question Title * 11. Emergency Medical Information for Participant #1 Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 12. Emergency Medical Information for Participant #2 Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Thank you for registering for the 1st Annual Cornerstone Youth Center Cardboard Cup!We look forward to seeing you August 16th, 2014 after the Harvest Festival Parade.Monroeville Indiana Park PondRegistration/Sign In begins at 12pm1st race begins at 1:00pmIf you have any questions please contact Mell Depew @ 260-623-3972 Done