Team Wellness Registration Form

Please complete all fields on this form and click submit to register.

Personal Information:

First Name		Last Name
Street Address		Address (cont.)
City		State         Zip Code
Daytime Phone		Evening Phone
Email

Age (on race day)  
Birth Date  -- mm/dd/yy
Gender Male  Female
Emergency Contact Name   Relationship
Emergency Contact Number

How did you hear about Team Wellness? 
Please indicate your (unisex) T-shirt size  Small Medium Large X-Large XX-Large

Which race will you complete?

LA Marathon (5K (3.1 miles) - March 20, 2010)
LA Marathon (full marathon (26.2 miles) - March 21, 2010)
Both the 5K and the full marathon

I plan to: Walk  Run  Walk/Run

Participant Waiver and Release

I understand and agree that there are risks, foreseeable and unpredictable, associated with any exercise program.  I am participating in the Team Wellness walk/run training program voluntarily and I am aware of these risks and agree that my participation is at my own risk.  I certify that I am physically fit and know of no restrictions imposed on me by my own physician or any physician that would in any way prevent me from actively participating in the Team Wellness walk/run training program.

I acknowledge that participating in a marathon, half marathon, 10k, 5k or any other length race (hereinafter "Event") is an extreme test of a person's physical and mental limits and carries with it the potential for serious injury, death, and property damage. I acknowledge and agree that it is my responsibility to determine whether I am sufficiently fit and healthy enough to safely participate in an Event, and I attest and certify that I am or will be sufficiently fit and physically trained to participate in any Event which I elect to enter. I have no physical or medical condition which would endanger myself or others if I participate in any Event, or would interfere with my ability to safely participate in any Event. I accept responsibility for the condition and adequacy of my competition equipment and my conduct in connection with any Event. I understand and acknowledge the dangers associated with the consumption of alcohol and/or drugs before, during and after any Event and I recognize that consumption of alcohol and/or drugs might impair my judgment and/or motor skills. I assume full responsibility for any injury, loss or damage associated with my consumption of alcohol and/or drugs.

On behalf of myself, my executors, administrators, heirs, next of kin, successors and assigns, and anyone else who might sue on my behalf, I HEREBY WAIVE, RELEASE, and FOREVER DISCHARGE The Wellness Community-West Los Angeles, its officers, directors, employees, agents, volunteers, representatives, successors, and entities, from any and all claims, causes of action, damages, losses (economic and non-economic), and liabilities of every kind (collectively "Claims"), for death, personal injury, or property damage, which may arise out of, result from, or relate to my participation in, or my traveling to or from, the Team Wellness walk/run training program and the Event, including but not limited to any Claims for theft, damage to any equipment, negligence, partial or permanent disability, Claims relating to the provision of first aid, medical care, medical treatment, or medical decisions (at an Event site or elsewhere), and any Claims for medical or hospital expenses.

I understand that I may be photographed and I give my permission to use my name and/or photograph or video in any broadcast, telecast, internet or print media account of the activities of the Team Wellness walk/run training program or any purpose The Wellness Community-West Los Angeles may have in using the like.

  Yes, I have read the above waiver and release and agree with the above terms.   

Today's Date:  mm/dd/yy
Parent Name: 

(Please provide parent or legal guardian name if under 18)

Participant Commitment

I understand that filling out this form, fundraising for TWC-WLA and submitting a training fee, if needed, qualifies me as a member of Team Wellness and allows access to all training functions. 

I understand that there is a fundraising minimum requirement of $300.00

Date: -- mm/dd/yy
Parent Name:

(Please provide parent or legal guardian name if under 18)

STEP 2

Register for your race(s) online at www.lamarathon.com, and select The Wellness Community as your Charity Training Team in the drop down menu. Then, return to this page and complete the rest of this form.

I have registered for the LA 5K Marathon race and paid the registration fee of $35.

I have registered for the LA Marathon Full Marathon Race and paid the registration fee of $125.

Optional Training Fee for Full Marathoners Only: $200, payable to TWC-WLA (please write "Team Wellness Training Fee" in the comment field)

I have paid the non-refundable marathon training fee, which will confirm my place in the Club 26.2 training program as a member of TEAM WELLNESS!

 

Your completed registration form must be received by TWC-WLA before your training with Team Wellness can begin.