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X Beach Charity Challenge 18 May 2014 9:00-1:00 Team registration: Two per team

X Beach Charity Challenge 18 May 2014 9:00-1:00 Team registration: Two per team Team name (be creative): Division: circle one Male-Male Male-Female Female-Female Parent-Child (13-18) Military-Military First participant Info Second participant Info First Name First Name

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X Beach Charity Challenge 18 May 2014 9:00-1:00 Team registration: Two per team

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  1. X Beach Charity Challenge 18 May 2014 9:00-1:00 Team registration: Two per team Team name (be creative): Division: circle one Male-Male Male-Female Female-Female Parent-Child (13-18) Military-Military First participant Info Second participant Info First Name First Name Last Name Last Name Email address Email address Adult Shirt Size (circle one): Adult Shirt Size (circle one): Small, Medium, Large, XL Small, Medium, Large, XL PLEASE READ THE WAIVER AND SIGN BELOW: I hereby grant permission to event organizers and its agents to photograph, and record video of, my image, likeness or depiction and/or that of my minor children (if applicable) and to edit, crop or retouch such photographs and videos, and waive any right to inspect the final photographs and videos. I hereby consent to and permit photographs and videos of me and/or those of my minor children (if applicable) to be used by event organizers and its agents for any purpose, including advertisement purposes, and in any medium, including print and electronic. All grants of permission and consent, and all covenants, agreements and understandings contained herein are irrevocable.   I, the undersigned, waive and release myself, my heirs, executors and administrators, any and all rights and claims for damages, demands and any other actions whatsoever, which I may have against the race organizers, host Government entities, all participating sponsors and supporters of those entities, successors, representatives and assigns, arising out of my participation in this event. This includes any and all injuries suffered by me as a result of my participation in this event and or damage to my personal equipment. I consider myself adequately trained for the completion of this event. Should I suffer an injury or illness, I authorize officials of the emergency services to use their discretion to have me medically treated and transported to a medical facility and I solely take full responsibility for this action and all my actions related to this event. YOUR PARENT OR GUARDIAN MUST SIGN IF YOU ARE UNDER 18 Participant #1 (aka X Beach Bum) Signature Participant #2 (aka X Beach Bum2) Signature Include a check/money order payable to X Local Charity Challenge Inc and send registration and payment to X Beach c/o Children of Fallen Patriots 419 Third Street NorthJacksonville Beach, FL 32250 Or register online at www.xbeachcharitychallenge.com

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