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		Citizenship USA           Other

Bib Name (11 character maximum - must be submitted by 1/14/11)

Age (on race day)      
Birth Date  -- mm/dd/yy
Gender Male  Female
Marital Status Single  Married

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

Which race will you complete?

LA Marathon 5K (3.1 miles) - Saturday, March 19, 2011
LA Marathon (26.2 miles) - Sunday, March 20, 2011

I plan to: Walk  Run  Walk/Run

Is this your 1st LA Marathon? Yes  No

How many marathons have you finished?  

Expected Finishing Time- Hours:       Minutes:  

Education (select highest attended) High School/Other  College Grad School

Occupation

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 and TWC-Foothills, 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 or TWC-Foothills 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, submitting a registration form and fundraising for TWC-WLA or TWC-Foothills 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 $1,800.00

Which community are you raising funds for?

The Wellness Community-West Los Angeles
The Wellness Community-Foothills

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

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

STEP 2

Submit your registration fee online through our secure site by clicking link below. Link will open in a new window. Make sure to return to this page and click "Submit Form" once you have made your payment.

Registration Fee: $250, payable to TWC-WLA (please write "Team Wellness Registration Fee" in the comment field)

 I have paid the non-refundable registration fee online, which will confirm me as a member of TEAM WELLNESS!
  I have mailed a check to TWC-WLA for the non-refundable registration fee, which will confirm me as a member of TEAM WELLNESS!
  I have not paid my registration fee yet.

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