PVNT 2019 Roller Ski Program - ADT

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Team name   First name   Last name   Email address   Date of birth    MM 01 02 03 04 05 06 07 08 09 10 11 12    DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    YYYY 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920    Gender -- Male Female   Phone #   Address   Emergency contact name   Emergency phone #   Event entry fee 120.00 USD

Skier's cell phone # or N/A  *   Skier's email address or N/A  *   Mother's cell phone or N/A  *   Father's cell phone or N/A  *   Mother's email address or N/A  *   Father's email address or N/A  *   Does the skier have any medical conditions or medical allergies?  * NoYes   If YES, explain what they are (if none, enter N/A)  *   Is there any additional information PVNT needs to know about this skier?

Discount or coupon code   Subtotal 120.00 USD Discount 0.00 USD Total 120.00 USD Calculate

Please review the waiver provided by the event organizer and click the check box below to accept it. Print waiver Plain Valley Nordic Team, Inc. Release and waiver of liability, assumption of risk agreement, and medical consent to treatment agreement. In consideration of myself OR my child being permitted to participate in the Nordic Ski Center/Club activities (“Activities”) of the above named Nordic Ski Center/Club, I represent that I do, on behalf of myself OR child: 1. I acknowledge, agree and represent I fully understand the nature of Nordic skiing, any kind of dryland training, hiking, running, roller skiing, cycling, stand up paddle boarding, and Nordic Ski Center/Club activities, and that I am OR my child is qualified, in good health, and in proper physical condition to participate in such activities. 2. I fully understand that (a) Nordic Ski Center/Club activities involve inherent risks and dangers of serious bodily injury, and or death, (b) these risks and dangers may be caused by my own (or child’s) actions or inactions, or omissions, intentional or otherwise, or the actions or inactions of others participating in the activities, and/or the condition of which the Activities take place and/or the conditions of the Nordic ski equipment or other equipment, that I OR my child may use/rent/borrow for participating in any such activity. 3. I hereby agree to allow the Plain Valley Nordic Team, Inc., Plain Valley Nordic Trails, Inc., and/or Plain Hardware, Inc., to use and/or share photos and videos of myself or my child for any purpose without compensation. 4. I hereby agree for myself and for my child (if applies), to release, discharge, indemnify, and covenant not to sue the above listed Nordic Ski Center/Club or its parent organization, its respective administrators, directors, agents, officers, members, volunteers, and employees, any sponsors, advertisers, and if applicable, owners and leasers of premises of property on which the activities take place (each considered one of the “Releasees” herein) from all liability, claims, demands, losses or damages on my account caused or alleged to be caused in whole or in part by the negligence of the “Releasees” or otherwise. I further agree that if, despite this release, waiver of liability, and assumption of risk, that I, or anyone on my behalf OR on behalf of my child, makes a claim against any of the Releases, I will indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost which may incur as the result of such claim. 5. I fully accept and assume all such risks and all responsibility for losses, cost, damages that I OR my child incurs as a result of my OR my child’s participation in the activities. My signature signifies that I fully understand and agree to be bound by this Release and Waiver Agreement, for myself and for my underage child (if applicable), and agree that if any portion of this agreement is held to be invalid the balance, not withstanding, shall continue in full force and effect. 6. I agree to notify Plain Valley Nordic Team, Inc., immediately via phone at (509) 630-1107 in the event of an injury or accident and to complete a signed accident report immediately following the injury and submit it to Plain Valley Nordic Team, Inc., located at 18636 Beaver Valley Road, Leavenworth, WA, 98826. 7. The term of this liability release shall be in perpetuity, or until cancelled in writing and delivered to Plain Hardware, Inc., via certified mail. MEDICAL RELEASE I, the parent or legal guardian of the above named minor, in the event of injury to my child while in the care of the Plain Valley Nordic Trails, Inc., do hereby give my permission to seek medical attention for him/her and further I approve his/her being transported to a clinic or hospital for the purpose of having authorized licensed medical personnel treat such injury. I, also, hereby release the Plain Valley Nordic Team, Inc. and their members or agents from all liability for any injuries/damages whatsoever arising from my child’s participation in or presence at any of the ski programs, practices, or events. I accept the terms of the waiver Name of parent or guardian who approves this activity Please enter your name here