Kettle Kick-off Classic Registration and Waiver FormREQUIRED for EACH participant

Please print all information and return to your team captain with your commitment/registration fee (if applicable)

My Kettle Kick-Off Classic t-shirt size is: _____. If no size is indicated, the participant will receive an XL.

REGISTRATION FEE Make check payable to and send to: The Salvation Army, 17 S. Pennsylvania Ave, Wilkes-Barre, PA 18701 Individuals:Before November 12, 2010 $ 10.00Relay Day $12.00

Our team captain has paid our fee Enclosed is my individual registration fee $______

WAIVER: Each Team Member MUST read and sign.

In consideration of the participation in programs administered and conducted by The Salvation Army, the undersigned, on behalf of himself, herself or itself, and all successors, heirs, assigns, and representatives does (do) hereby fully release and forever discharge The Salvation Army and its officers, directors, employees, agents, representatives, affiliates, and members the (“Released Persons”) from any and all liability, damages, demands, claims, actions and causes of action of any kind or description whatsoever, whether arising out of contract, tort or otherwise, in law or in equity, which the undersigned may now have or may in the future have against The Salvation Army and the Released Persons, arising from participation in any program that was administered or conducted by The Salvation Army or the use of its facilities, including acts presently unknown but committed prior to the date of the execution of this agreement.

In witness whereof, the undersigned has (have) signed this General Release on this date of:________________Print Name:____________________________ Signature/Guardian Signature ___________________________

Team Name/Theme: ______________________________________________________

Team Captain’s Name: ____________________________________________________

Participant’s Name: ___________________________ Address: ____________________

City: _______________________ State: _________________ Zip: __________________

Home Phone: ________________________ Cell Phone: _________________________

E-mail Address: __________________________________________________________

I am 18 years or older (circle one) Yes No Age: ________

Emergency Contact Name: _________________________________________________

Emergency Contact Phone Number: _________________________________________

Address of Signer: ______________________Signature of Witness: __________________________________