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Conyers Police Explorer Post 2222 Dash into Spring 5K Benefiting Conyers Police Explorers Liability Waiver Form PLEASE PRINT Name _________________________________________________________________________________________________ Address ________________________________________­­­­­­­­­_________________­­­­­­­­­_­______________________________________ Phone _________________________________       E-mail _______________________________________________________ Emergency Contact   Name __________________________________ Phone Number _________________________________ Fun run ____   5K ____     Is this your first time participating in a Fun Run or 5K event   Y/ N Release of Liability Waiver:  In consideration of the acceptance of this entry, I waive all claims for myself and my heirs, executors, administrators and assigns against the City of Conyers, the Conyers Police Department, its elected officials, employees, agents, contractors, officers, directors, representatives, sponsors, cooperating and coordinating groups and individuals associated with this event, and I will indemnify, defend and hold them harmless for any and all injuries, illness or cost of medical treatment which may result from my participation in this event, including reasonable attorney’s fees and expenses. I certify that I am physically fit for this event and understand the risks involved by participating in this event.  _____________________________________                  ____________________ Parent/Guardian Consent Form and Liability Waiver Participants Name: _______________________________   Date of Birth _________   Sex ____ Parent/Guardian Name: ____________________________   Home Phone __________________ I, _______________________________________, grant permission for my child, _________________________, to participate in the Conyers Police Department’s Fun Run/ 5K. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor (“participant”). I hereby approve and agree to the foregoing. Medical Matters:  I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. _______________________________________________                      _______________________ Signature                                                                                              Date

For good and valuable consideration, the adequacy and sufficiency of which is hereby acknowledged by the parties hereto and without any further consideration from the City of Conyers or any other party (collectively, “you”), I, ____________________________ (“I” or “me”) hereby irrevocably grant permission to you and your licensees, designees and/or assigns to use all or part of your videotaped or filmed footage or photographic or video stills of me in any and all manner and media now known or hereafter devised (including, but not limited to, in connection with the marketing and promotion of you and further including, but not limited to, television broadcasts (whether free, basic, pay, cable, satellite or digital broadcast), motion pictures (whether theatrical exhibition, home video, dvd, VHS or digital transmission), websites, webcasts, podcasts, mobile, digital, video image podcasts and/or any other audiovisual format now known or hereafter developed throughout the world in perpetuity.  You may edit this footage and/or still photographs that embody my image, name, likeness or other indicia as you see fit.  I consent to the use of my picture, name, likeness, voice and biographical material about me in connection with you and/or any and all advertising, marketing or publicity materials associated with you.  I waive any and all moral rights in connection with the use of these materials.  I expressly release you, your members, agents, officers, employees, licensees, designees, successors, and assigns from and against any and all claims which I have now or may have in the future for invasion of privacy, defamation, right of publicity, breach of contract and/or any other cause of action arising out of the creation, production, distribution, broadcast, exhibition, marketing, merchandising or other exploitation of my name, likeness and/or the materials.  I further acknowledge that you own all rights, title and interest in any and all results and proceeds from said use, interview, footage, stills, appearance and/or other exploitation of the materials.  You are not obligated to make any use of this footage and/or stills or exercise any of the rights granted you by this release.  Credit, if any, provided by you shall be at your sole discretion.  The failure by you and/or any third party to afford such credit shall not be deemed a breach of this Agreement.  You shall have the right to assign this Agreement and/or any of your rights hereunder to any third party whatsoever, and this Agreement shall inure to the benefit of any such assignee(s).  I understand that I am not entitled to any money, royalties, fees, sums or other monies for the grant of rights and releases provided by me herein.  I further understand and agree that in the event it is ultimately determined by a court that you have committed a material breach of this Agreement, the damage, if any, caused to me thereby will not be irreparable or otherwise sufficient to entitle me to seek injunctive or other equitable relief, and that my rights and remedies in any such event shall be strictly limited to the right, if any, to recover damages in an action at law and any such damages will be limited to any amounts paid under this Agreement, if any.  This Agreement shall be governed by and construed in accordance with the laws of the State of Georgia, without giving effect to the principles of conflicts of laws thereof.  Any dispute arising out of or relating to the terms and conditions of this Agreement shall be determined exclusively in the Superior Court of Rockdale County.  This consent and release expresses the entire understanding between you and me, and I agree that no oral understandings have been made with regard thereto.  The provisions herein shall be binding upon me and my heirs, executors, administrators and assigns.   In witness hereof and in full understanding of the foregoing, I have signed this consent and release on this _____ day of ________________, 20___. Agreed: Signature: _______________________________ Address: ________________________________   IF PARTICIPANT IS A MINOR   I, _____________, represent that I am a parent and/or legal guardian of _______________, the minor who has signed the above release, and I hereby approve and agree to the foregoing. Name: __________________________________ Signature: _______________________________ Address: ________________________________