U.S. Achilles Athlete With Disability Membership Application
TERMS AND CONDITIONS: I know that participating in Achilles running or other athletic events is potentially hazardous. I agree not to enter any Achilles race, activity, or sponsored event unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with participating, including, but not limited to: falls, contact with vehicles, other participants, spectators, or others, the effect of the weather, including high heat, extreme cold and/or humidity, traffic conditions of the road, all such risks being known and appreciated by me.

I understand that (1) participation with Achilles International is strictly voluntary, and (2) I am only to receive/provide running companionship, advice, and encouragement from my fellow Achilles athletes/volunteers/guides. If anything else is asked of me, or if I am otherwise uncomfortable or concerned, I will bring it to the immediate attention of my chapter leader.

Having read this Waiver and knowing these facts, and in consideration of your accepting my application, I, for myself or for my child and anyone else entitled to act on my behalf, waive and release, and agree to indemnify and hold harmless the local chapter of Achilles International to which I belong (including all local Chapter directors, officers, leaders, members, athletes, volunteers, guides), the local county and city departments of Parks and Recreation, Achilles International (aka Achilles Track Club), Achilles Kids Program, New York Road Runners, Road Runners Club of America, The City of New York and all its agencies, all sponsors of Achilles and any of their races or events, members and volunteers, from present and future claims and liabilities of any kind, known or unknown, arising out of my participation in any Achilles event or related activities, even though that liability may arise out of ordinary negligence or fault on the part of the persons named in this Waiver. By registering for a New York Road Runners Race or any other race through Achilles International, I hereby grant my permission to Achilles International to act as proxy on my behalf for that race with full authorization to execute consents, waivers and releases included in the Achilles International registration. I further grant my permission to all the foregoing to use photographs, motion pictures, recordings, or any other record of my participation in Achilles International for any legitimate purpose, without remuneration.

If applicant is under the age of 18 years of age, OR otherwise potentially deemed incompetent and/or unable to legally consent for themselves, personal information for a parent or guardian must be provided before submission.

If for any reason, the applicant is unable to read this document clearly and independently, then the document must be read to the volunteer/member, and then witnessed and co-signed by a third party individual.

Untitled Title
Waiver Agreed To? *
IN COMPLETING AND SUBMITTING THIS FORM, I INDICATE THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ABOVE TERMS AND CONDITIONS.
Required
First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Address Line 1 *
Your answer
Address Line 2
Your answer
City
Your answer
State / Commonwealth / Territory
Your answer
Zip Code *
Your answer
Preferred Phone Number *
Please indicate type: cell, home, work
Your answer
Email address *
Your answer
Date of Birth *
format 00/00/0000
Your answer
Gender *
Disability: *
Your answer
Do you use a handcycle, pushrim wheelchair or other equipment for racing? *
Required
Running Level *
check one
T-shirt Size *
check one
Name of Local Chapter *
For a list of U.S. Chapters, please visit http://www.achillesinternational.org/national-chapters/
Do you want to receive communications from Achilles International? *
Required
Is there anything else you would like us to know?
Your answer
If applicant is under the age of 18, OR otherwise potentially deemed incompetent and/or unable to legally consent for themself, enter the name of parent or guardian, along with phone number below.
Your answer
If you are acting as a 3rd party witness to a reading of the waiver, please provide your name and phone number below.
Your answer
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