How do I participate?

Fill out the following form and send it back to IPCRI by email to: gershon@ipcri.org

FULL NAME: ……………………………………………………………………………………………

COUNTRY: .……………………………………………………………………………………………

ADDRESS: ………………………………………………………………………………………………

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TELEPHONE: ……………………………………………………….

FAX: ………………………………………………………………….

EMAIL: …………………………………………………………………………………………………..

AGE: …………………………

SPECIAL DIETARY REQUIREMENTS: ……………………………………………………………..

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DATE OF ARRIVAL: ……………………………………………………………………………………

CREDIT CARD INFORMATION

TYPE: ……………  NUMBER: ………………………………….  EXPIRATION: ……………….

I have read the following Statement of Agreement and I agree to all of the conditions specified in this agreement. 

_____________________________                     ___________________________

Signature                                                          Date

STATEMENT OF AGREEMENT:

I ACKNOWLEDGE that the Walk the Green Line event that I am going to participate in involves a potentially dangerous activity. I hereby assume all the risks of doing this Walk, regardless of their cause. I promise to Walk in a safe and prudent manner, so as not to endanger myself or others. In consideration of my application to participate in this Walk, I hereby execute this Waiver and Release from Liability on behalf of myself, my personal representatives, my administrators, my heirs, my next of kin, my survivors, my successors, and my assigns, as follows:

A. I WAIVE, RELEASE, DISCLAIM and FOREVER DISCHARGE from any and all liability for me while participating in the Walk the Green Line Walk sponsored by IPCRI on May 24-26, 20107,  and all other directors, officers, employees, volunteers, representatives, agents, assigns, funders and sponsors of IPCRI. Moreover, in the event that any legal claims arise out of or in connection with the said event, jurisdiction for such legal action rests solely with the state of Israel, where IPCRI is based.

B. I INDEMNIFY AND HOLD HARMLESS the entities and persons specified in paragraph A above from any and all liability, loss, demand, claim or action at law or in equity that may hereafter be made or brought by those individuals or entities as a result of any of my actions during this ride. This indemnification and hold harmless agreement obligates me to defend any action brought against the entities and persons specified in paragraph A above as a result of any of my actions during this ride. Should I refuse to undertake my responsibilities under this paragraph, I will be liable for attorneys fees and costs incurred by the entities and persons specified in paragraph A above in defending any action brought against them as a result of any of my actions or those of my family members during this ride.

C. I CONSENT to receive medical treatment that may be deemed advisable as a result of any injuries I receive during this Walk and agree that I am solely responsible for all costs, including diagnosis, treatment, medical transportation, and evacuation, that may become necessary for me or another person as a result of any of my actions during this ride.

D. I AGREE that any photographs and video footage taken of me during my Walk, as well as any written documents I submit to IPCRI, may be printed, reproduced and published in any manner anywhere without any further consent by me or my family members and without any compensation to me.

E. I AUTHORIZE IPCRI to charge the balance of my fundraising requirement to my credit card if I have not completed my fundraising requirement by May 10, 2010.

F. I CERTIFY that I have read this document, understand its contents in their entirety and have executed this document below without reservation or duress.

 

(INITIAL THE BOTTOM OF THIS PAGE AND FAX WITH

PARTICIPATION FORM)

CLICK HERE TO Download the participant form