Mail checks payable to the Arkansas Dietetic Association (ArDA) along with this

entry form to: ArDA, PO Box 55234, Little Rock, AR 72215 or Register online

(Please Print) First Middle Last

Address_____________________________________________________________________________

Street City/State Zip

Email Address____________________________ Phone #___________________

Date of Birth_____________ Age_______ Student: Yes No

School Representing: _______________________________________________________

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The Arkansas Run/Walk involves an aerobic workout which may include risks such as, but not limited to, falls, interaction with other

participants, and effects of weather. In consideration of being allowed to participate in this event, I hereby expressly assume all risks

including personal injury and death, arising out of my participation in related activities.

It is my responsibility to dress appropriately. Although refreshments and other assistance may be made available during this event, I am

solely responsible for my own health and safety. I represent and warrant that I am physically fit and able to participate in this event and I

agree to stop and request assistance if I experience any symptoms such as, but not limited to, dizziness, excessive fatigue, shortness of

breath, pain or any other condition which would make it difficult or unsafe to continue.

I agree for myself, my heirs, executors and administrations, to not sue and release, indemnify and hold harmless the Arkansas Dietetic

Association, Park and their affiliates, officers, directors, volunteers and employees, and any sponsoring businesses and organizations and their agents and employees from any and all liability, claims, demands, and causes of action whatsoever, arising out of my participation in this event and related activities whether it results from negligence of any of the above or from any other cause.

This release and indemnification agreement shall be as broad and inclusive as is permitted by the State or Province in which the event is conducted. If any portion of it is held invalid, the balance shall continue in full force and effect.

I am the legal guardian of the participant, and I hereby consent to his/her participation. I have read the foregoing release and indemnification agreement, and I hereby agree on behalf of myself and the participant to its terms.

__________________________________ ________________________________ ______________________

Print name of Parent/Guardian Signature of Parent/Guardian Date

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