Tucker's Trek Registration

To sign up for Tucker's Trek 2016

please complete the following form:

 

First Name 
Last Name 
Street Address 
City, State, Zip 
email address 
Age 
Gender  
Select Event 
Shirt size 
Participant #2 First Name 
Participant #2 Last Name 
Participant #2 Age 
Gender Participant #2 
Participant #2 Select Event 
Participant #2 T-shirt size 
Participant #3 First Name 
Participant #3 Last Name 
Participant #3 Age 
Gender Participant #3 
Participant #3 Select Event 
Participant #3 T-shirt size 
Participant #4 First Name 
Participant #4 Last Name 
Participant #4 Age 
Gender Participant #4 
Participant #4 Select Event 
Participant #4 T-shirt size 
I AGREE TO THE WAIVER/RELEASE FORM AT THE BOTTOM OF THIS PAGE 
I have verified that the Quantity selected below matches the number of participants entered above.
 
Payment Information (All Fields Below are Required) 
Payment Description  Entry Fee: Please select the Number of participants you are paying for @ $30.00 each.
Quantity 
Payment Amount  $30.00
 
First Name on Credit Card 
Last Name on Credit Card 
Billing Street Address 
Billing City 
Billing State 
Billing Zip Code 
Card Holder Email 
Card Number 
Card CVV Code (3 or 4 digits) 
Card Expiration (ex 09/2018) 
To prove you are a human, please tell us which has wheels?

 

Waiver/Release and Indemnification for Tucker's Trek:  I agree, for myself, my heirs, executors, and administrators, to not sue and to release, indemnify and hold harmless Emily's Power for a Cure, its affiliates, officers, directors, volunteers, and employees, and all 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 the negligence of any of the above or from any other cause. Furthermore, I authorize the use, copyright, or publication of my name, image, or voice as may be captured by photograph or recording while participating in this event in any medium for any purpose, including illustration, promotion, or advertisement. Foregoing release and indemnification shall be as broad and inclusive as is permitted by the State in which the event is conducted. If any portion of it is held invalid, the balance shall continue in full force and effect.  I have read, understand and agree to the terms of this agreement.  I hereby consent to my participation.  I have read the foregoing release and indemnification agreement and hereby agree to its terms.

Site Sponsored by
Chattanooga Allergy Clinic
Emily's Power For A Cure - P.O. Box 1387 | Hixson, TN 37343 | powerforacure@gmail.com