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Captain Request - Lory's Place 5K 2019                              
May 20, 2019
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Current Captain Application? *
I have filled out the Captain Application on the Michigan Chapter website at:  https://www.myteamtriumph-mi.org/become-a-captain
Last Name *
First Name *
Street Address *
City *
State *
Zip *
Phone *
xxx-yyy-zzzz
Email *
Emergency Contact Name *
Emergency Contact Phone *
Birthdate *
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DD
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YYYY
Shirt Size *
mm/dd/yyyy
Teammate Request
If you would like to team with specific Angels for this event, please share their names here (while we cannot guarantee teaming arrangements, we will do our best to honor your request):  
Event Waiver *
In an effort to consolidate waiver signatures between myTEAM TRIUMPH and specific event signup pages, the titled event's waiver statement is included here. This allows myTEAM TRIUMPH to capture your waiver on behalf of this event host, and as a myTEAM TRIUMPH participant.  In consideration for acceptance of this entry, I, the undersigned, intending to be legally bound, hereby for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I may have against the event director, RunSignup.com, its agents assisting with the event, sponsors, sponsor’s representatives and employees, Lory’s Place employees, management, Hospice at Home, Inc. dba Caring Circle, the City of St. Joseph, Lakeland Health and all its affiliates, The Whirlpool Corporation and their representatives, successors, and assigns for any and all injuries or illness which may result directly or indirectly from my participation in the Run, Walk, Rock event and related activities. This release includes any and all injuries or damages suffered by me before, during or after the event. I further state that I am in proper physical condition to participate in this event. I authorize Lory’s Place, Hospice at Home, Inc. and/or Lakeland Health to use any photographs, personal narratives, interviews, audio and/or video recording of my participation in any Lory’s Place, Hospice at Home, Inc. dba Caring Circle and/or Lakeland Health event for any and all purposes.I certify as a material condition to me being permitted to enter this race that I am physically fit and sufficiently trained for the completion of this event and that my physical condition has been verified by a licensed Medical Doctor. By submitting this entry, I acknowledge (or a parent or adult guardian acknowledges for all children under 18 years) having read and agree to the above waiver.
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