Mark A. Chapman Piotique 10K/2 Mile Run

In consideration of your acceptance of this entry, I hereby, for myself, my heirs, executors and administrators, waive any and all rights and claims for damages I may have against sponsors, coordinating groups, and any individuals associated with the event, their representatives, successors and assigns for any and all injuries suffered by me in connection with said event. Also, none of the above are responsible for the loss of personal items nor any other form of aggravation in connection with said event. I have been warned I must be in good health to participate in this event. In filling out this form, I acknowledge that I am an amateur in such events. I also give my permission for the free use of my name and picture in any broadcast, telecast or print media account of this event.