Street Scramble Bellingham

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Who are you registering? Yourself Someone else Team name   First name   Last name   Email address   Confirm 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 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 1919 1918    Gender -- Male Female   Age Category Choose one Adult 22+ Adult 22+ w/child on team Child 5 and under Child 6-12 Years old Youth 13-21 Years old   Event entry fee TBD

Phone Number  *   Address  *   City  *   State or Province  *   ZIP or Postal Code  *   Country  *   Emergency Contact Name  *   Emergency Contact Phone #  *   Team Name  *   Participating on foot or bike?  * Choose One Foot Bike   Number of Team Members (Max. 6)  *   List Team Members. Each Person Must Register Individually  *   Do you want to receive emails about Street Scramble event news and schedules? Yes please! Already on the list. No thank you.

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Please review the waiver provided by the event organizer and click the check box below to accept it. Print waiver I know that participating in this Street Scramble event is potentially dangerous. The dangers include but are not limited to automobile traffic; falling or colliding with the ground, objects I may encounter, or others; medical conditions; weather; and both natural and manmade conditions of the course. I alone am responsible for my safety while I participate, and I should not participate unless I am medically able and properly trained. I have read and understood this waiver, and in consideration of acceptance of my application for Street Scramble, I, for myself and anyone entitled to act on my behalf, waive and release the organizers (Meridian Geographics, LLC), the United States of America, the State of Washington, Whatcom County, the city of Bellingham, and all other land owners and land managers, their representatives and successors, from all claims or liabilities of any kind arising out of my participation in this event, even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to the organizers to use photographs or audio/video recordings of me for any legitimate purpose. I accept the terms of the waiver Name of parent or guardian who approves this activity Please enter your name here