Mud Maxx 06/09/12

Please mail completed application to:
Steve & Paula Boone, 19903 January Drive, Humble, TX 77346
Cellular phone 713-826-5833 email steveboone@aol.com

Name _____________________________________                    Male / Female

Address ___________________________________       Age on race day ________            

City, State, Zip _______________________________                  

Phone (day) ________________ night ________________          

Email address ___________________________________   

"Mud Name" on your race bib ___________________________________________

Mud Maxx 5K _____     Shirt size S / M / L / XL / XXL / XXXL

Fees: $25 (thru 5/26/12)   $30 (5/27/12-6/8/12)   $35 Race Day                                 $ ________

Children's 1 Mile Mud Mini _____  Children's Shirt size YS / YM / YL
 
Fees:   $15       thru Race Day                                                                                         $ ________

Donation to the Shriner's Hospitals for Children                                                            $ ________

Sponsor a Mud Hole    __________________  (Title for sign)    $25                      $ ________
                                                                                                                                 
Make check payable to: Mud Maxx                                               Total Enclosed    $ ________

Waiver Must Be Signed
Waiver: All participants in the Mud Maxx events assume all risk of participation in the event by signing the release agreement.  I the undersigned athlete on behalf of myself and on behalf of my heirs, my executors, my administrators and my trustees, waive and release any and all rights and claims for any loss(es), injuries and damages including, but not limited to demands or actions for negligence, premises liability, emotional injury, intentional conduct, tort claims, and any other actions or demands of whatever nature, I have or may have against 1) Mud Maxx, 2) its officials, agents and representatives, 3) Shriners International, 4) all sponsors of the event in which I may participate whether my participation is as a contestant or as a spectator.  I acknowledge that I am aware of the inherent risks involved in this event and I voluntarily assume the risks.  I attest and verify that I am physically fit and I have sufficiently trained for the competition of the above-mentioned event in which I participate.  I hereby grant full permission to any and all of the foregoing to use my name, and/or my picture in any account of this event for any purpose whatsoever.  I have read the entry information provided for the event and certify my compliance by signing below.  Athlete acknowledges that the entry fee is non-refundable and non-transferable.

Signature of athlete_______________________________ Date ___________

* Signature of parent/guardian ______________________ Date ___________

*(if athlete is under 18) I certify that my son/daughter has my permission to compete in the Mud Maxx events, is in good physical condition and that race officials have my permission to authorize emergency care if necessary.