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Waiver of liability: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound, hereby, for myself, my family, my heirs, executors, and administrators, forever waive, release, and discharge any and all rights and claims for damages and causes of suit or action, known or unknown, that I may have against the Anchorage Running Club (ARC) and the Anchorage RunFest (ARF), the Municipality of Anchorage, all independent contractors and construction firms working on or near the course, all ARC and ARF Committee persons, officials, and volunteers, and all sponsors of the events included in the ARF for any and all injuries suffered by me in this event. 

Medical: I attest that I am physically fit, am aware of the dangers and precautions that must be taken when running in warm or cold conditions, and have trained sufficiently for the completion of this event. I also agree to abide by any decision of an appointed medical official relative to my ability to safely continue or complete the ARF. I further assume and will pay my own medical and emergency expenses in the ARF of an accident, illness, or other incapacity regardless of whether I have authorized such expense. I hereby authorize the disclosure of medically related information concerning my health, injuries, incapacity, or medical emergency that may occur in the course of participating in this event, and to allow that information to be provided to a family member, friend, or event official of the ARF. Strollers and other distractions: I understand that strollers are not allowed on the course, and that I will be immediately disqualified from the race if found to be using one. I also agree that any use by me of an MP3 player, iPod, cell phone, or other electronic device while on the course will be done so in a reasonable manner, using common sense. I also understand that no support vehicles, including bicycles will be allowed on the course, except those approved by course officials. 

Transfers and/or refunds: I acknowledge that I will not transfer, give, sell, or exchange my entry and this bib to anyone under penalty for fraud, false impersonation, and theft. I further understand that under no circumstances will there be any entry fee refunds or rollovers to another year or event, and that the bib is not transferable under any circumstances. Any violation is subject to liquidated damages of $5,000 plus attorney’s fees. 

Photographs: I hereby grant full permission to the ARF and/or agents authorized by them, to use any names, photographs, videotapes, motion pictures, recording, or any other record of this event for a legitimate purpose at any time. 

Cancellation: I also understand that the event may be cancelled due to any of the following reasons, among others: weather conditions, natural disasters, or threats to local and/or national security including suspected terrorist activity. There will be no refunds. I have read this waiver and understand it. If less than 18 years of age, parent/guardian of participating minor must submit entry on the minor’s behalf. As the parent/guardian, I hereby acknowledge and execute the foregoing Waiver release for and on behalf of the minor named herein. In submitting this form I hereby authorize medical treatment for any injuries sustained during this event. It is understood that parent/guardian assumes full risk for and on behalf of said minor. 

IMPORTANT: By entering my name below as a participant or parent/guardian of a participant under 18 years of age and submitting this form, I hereby signify that I have read and agree to the terms of the above waiver.

PERMISSION FOR TREATMENT AND BILLING
MY CONSENT FOR MEDICAL TREATMENT

I, (The Athlete) consent to the procedures which may be performed during this visit and for ongoing medical care as a patient of the Providence Family Medicine Center (hereby called PFMC), including emergency treatment or services, and which may include, but are not limited to, laboratory procedures, x-ray examinations, medical and/or surgical treatment, and/or procedures, anesthesia and/or as medical services rendered the patient under the general and special instructions of the patients physician. I understand that:

A)     It  is customary, except in emergencies or unusual circumstances, that major procedures are not carried out upon a patient until he or she has discussed them with the physician or other health professionals and has agreed to the procedure(s);

B)     Each patient has the right to refuse any proposed procedure(s) and/or treatment(s);

C)     No patient will be involved in any research or experimental procedure(s) without his or her full knowledge and consent; and

D)    I understand that no guarantee has been made to me as to the result or cures that may be obtained from examination or treatment while a patient of PFMC.  

GENERAL INFORMATION
My Understanding of the Relationship between PFMC and the Physician Treating me
I recognize that all attending physicians who may be treating me are licensed practitioners who have been granted the privilege of providing medical care at PFMC. If I have been referred by, or am being referred to another healthcare provider, I authorize PFMC to release my clinical information to the provider for continuing care.  

Providence Family Medicine Center as a Teaching Facility
I understand that PFMC is a teaching facility and that physicians specializing in family practice medicine (resident physician), medical students, or other health profession students may be involved in my care. I recognize that these residents and students are supervised by a fully accredited faculty physician and other experienced staff.  Care given at the Medical Aid Station by providence personnel is free of charge. Emergency services, such as on site stabilization and emergency transport, provided by the Anchorage Fire Department, may be billed per their routine.   

My consent to PFMC to Release Information
To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize PFMC to disclose portions of my record, including medical records, to any person and/or corporation which is or may be liable for clinic services.

My Acknowledgment of Possession of an Advance Directive
PFMC recognizes a properly executed advance directive, declaration/living will or durable power of attorney for health care decisions of qualified patients. If you have any of the above, acknowledge by initialing below. Acknowledgement of my Advance Directive: (initial)