In consideration of submitting this entry for myself for this event, I, intend to be legally bound hereby for myself/child, my heirs, executors and administrators, waive and release any and all rights I have against Derrick City Volunteer Fire Department and all associates of Derrick City Volunteer Fire Department, the Commonwealth of Pennsylvania, the sponsors of this event, the volunteer staff, and any other sponsors and their representatives, successors, and assigns, for any and all injuries suffered by myself or child in this event. My child will participate in this event as an athletic entrant. He/she is physically fit and has sufficiently trained for the competition and their physical condition has been verified by a licensed medical doctor. I further hereby grant permission to the sponsors of this event and any other sponsors to use all information submitted in this application, and my likeness and voice, as well as photographs, video tapes, motion pictures, recording or any other record of this event, including race results, in which I may appear for any legitimate purpose whatsoever including but not limited to pre-race and post-race publicity by publishing to internet sites, in newsletters or newspapers.
My signature verifies I have read, understand and agree to the information above.