Beer Belly Two - Registration Form

Beer Belly Two Registration Form

Mail entry form to:
Beer Belly Two
PO Box 10792
Green Bay, WI 54307-0792

Make check payable to:
Beer Belly, Inc.

$15.00 : pre-registration by mail prior to June 18, 2011
$20.00 : after June 18, 2011 & on race day
$10.00 : children under 12 years old - anytime
NEW: Family Rate (up to 5 people per family)
$45.00 : pre-registration by mail prior to June 18, 2011
$55.00 : after June 18, 2011 & on race day

Please fill out the following fields, then choose 'print' from your file menu.
Or register on-line with Active.com (additional $3.25 Credit Card processing fee, accepts Visa, Master Card, AmEx).

Please check if new address
Last Name: First: MI:
Address:
City: State: Zip:
Phone: Affiliation:

(Tavern, group or business. The affiliation with the most participation will receive a plaque.)

Division: Male Female Age on day of race:

Run / Walk: I will be competing I will NOT be competing
only those competing will receive race numbers and be eligible for awards.

T-shirt size: No T-shirt-donation only Small Medium Large X Large XX Large (add $2)

All participants receive a T-shirt. Shirts must be picked up at pre-race pick-up or on race day. If you need it mailed, include an additional $3.00 (per shirt) for shipping and handling. Shirts will be mailed after race day. Sizes not guaranteed on race day.

Email address (optional):

I acknowledge that this athletic event is a test of a person's physical and mental limits and carries with it the potential for death, serious injury and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, athletic condition, lack of hydration, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and/or producers of the event. These risks are not only inherent to athletics, but are also present for volunteers. I hereby assume all risks of participating and/or volunteering in this event. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault.

I certify that I am physically fit, have sufficiently trained for participation, and have not been advised otherwise by a qualified medical person. I acknowledge that this Accident Waiver and Release of Liability form will be used by the event holders, sponsors and organizers of the event in which I may participate, and that it will govern my actions and responsibilities at said event. In consideration of my application and permitting me to participate, hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) Waive, Release and Discharge from any and all liability for my death, disability, personal injury, property damage, property theft or action of any kind which may hereafter occur to me, including my traveling to and from this event, BEER BELLY, INC., their directors, officers, volunteers, representatives, agents, event holders, event sponsors, and event volunteers; (B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this event, whether caused by the negligence of releases or otherwise.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and/or illness during this event. I understand that as this event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and assigns. The Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I hereby certify that I have read this document; and, I understand its content.

Entrant Signature:_______________________________________

4 root beer / beer stops - (2 miles = 3.23 beerlometers)

Sunday, June 26, 2011 - Race begins at 10:30am. - Finish line and beer tables close at 11:30am.

Suamico - 10 miles north of Green Bay. Take hwy 41-141 north to CR-M / Lineville Road (exit 173), turn right 1/4 mile to Lakeview Dr. (CR-J), turn left about 1 mile to 2999 Lakeview Dr.

Main Site Index Pledge Sheet http://gbit.com/beerbelly/register.htm