ACHILLES - NASHVILLE MEMBERSHIP APPLICATION FORM

Name *

First Name Last Name

Address *

Street Address
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City	State / Province
Postal / Zip Code	Country

Gender *

Male Female

Birthdate *

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Phone Number *

Area Code Phone Number

What is your disability *

Ethnicity: *

Emergency Contact: *

First Name Last Name

Relation: *

Phone Number *

Area Code Phone Number

E-mail *

Email Verification *

Do you use a wheelchair, handcycle, or pushrim? *

Yes No

If yes, please specify

Running Level *

Beginner Intermediate Advanced

T-shirt size *

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Waiver: I know that participating in Achilles running or other athletic events is potentially hazardous. I agree not to enter any Achilles race, activity, or sponsored event unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with participating, including, but not limited to: falls, contact with vehicles, other participants, spectators, or others, the effect of the weather, including high heat, extreme cold and/ or humidity, traffic conditions of the road, all such risks being known and appreciated by me.

I understand that (1) participation with Achilles International is strictly voluntary, and (2) I am only to receive/provide running companionship, advice, and encouragement from my fellow Achilles athletes/volunteers/guides. If anything else is asked of me, or if I am otherwise uncomfortable or concerned, I will bring it to the immediate attention of my chapter leader

Initial Here *

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Having read this Waiver and knowing these facts, and in consideration of your accepting my application, I, for myself or for my child and anyone else entitled to act on my behalf, waive and release, and agree to indemnify and hold harmless Achilles International - Nashville Chapter (including all Nashville Chapter directors, officers, leaders, members, athletes, volunteers, guides), Metropolitan Board of Parks and Recreation, Davidson County, and Nashville Tennessee, Achilles International (aka Achilles Track Club), Achilles Kids Program, New York Road Runners, Road Runners Club of America, The City of New York and all its agencies, all sponsors of Achilles and any of their races or events, members and volunteers, from present and future claims and liabilities of any kind, known or unknown, arising out of my participation in any Achilles event or related activities, even though that liability may arise out of ordinary negligence or fault on the part of the persons named in this Waiver. By registering for a New York Road Runners Race or any other race though Achilles International, I hereby grant my permission to Achilles International to act as proxy on my behalf for that race with full authorization to execute consents, waivers and releases included in the Achilles International registration. I further grant my permission to all the foregoing to use photographs, motion pictures, recordings, or any other record of my participation in Achilles International for any legitimate purpose, without remuneration. I have read this waiver and agree to the terms.

Name *

First Name Last Name

Date *

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Signature *

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*Printed Name and Signature of Parent or Legal Guardian if applying member or volunteer is under the age of 18 years of age, OR otherwise potentially deemed incompetent and /or unable to legally consent for themselves. If for any reason, the volunteer or member is unable to read this document clearly and independently, then the document must be read to the volunteer/member, and then witnessed and co-signed by a third party individual.

Name

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Date

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Signature

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