PRIMARY CONTACT

NAME:

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TEAM

1st PARTICIPANT:

2nd PARTICIPANT:

3rd PARTICIPANT:

4th PARTICIPANT:

5th PARTICIPANT:

TEAM NAME:

ADDITIONAL DONATION: I would like to make an additional donation to The Elizaveta Fund in the amount of : $25   $50   $100   $500   Other amount (please specify):

HOLD HARMLESS AGREEMENT

In consideration of the acceptance of the right to participate, by execution of this entry form, I hereby release and discharge The Elizaveta Fund and all sponsors of The Elizaveta Fund and their officers, employees, directors, agents and representatives and anyone else connected with the management, promotion or presentation of The Elizaveta Fund from any and all known or unknown damages, injuries or losses, judgements and/or claims from any cause that may be suffered by any entrant or participant to his or her person or property. Further, each entrant expressly agrees to indemnify all the foregoing entities, firms, persons and bodies from any and all liability occasioning or resulting from the conduct of any entrant, participants or spectators assisting or cooperating with entrant under the direction or control of entrant. Further, I agree than any photos or videos of myself and/or the persons registered with me as a result of this event may be used promotionally.

Please check this box to indicate that you have read and agree to the terms above.