Potomac River Swim for the Environment
June 5, 2010
Entry Aplication
Name:
________________________________________________________________

Address:
________________________________________________________________
________________________________________________________________
________________________________________________________________

Telephone:

(cell)_____________________________
(day)_____________________________
(evening)__________________________
(FAX)____________________________

Email address:
_______________________________

Date of Birth:
_______________________________

Estimated Time to Complete Swim:
_______________________________
Medical/Other Information to declare:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Statement on open water experience (dates, distances, time):
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

WAIVER AND AGREEMENT
As a condition of being accepted in the June 5, 2010, 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 4, 2010 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.

Signature: _______________________________ Date: ____________

 

Please sign and mail this sheet to:
Cheryl Wagner
3103 Hawthorne Dr, NE
Washington, DC 20017-1040

 

For more information:
(202) 387-2361 Home Phone
(202) 478-0948 Fax
cherylw@crosslink.net   Email