Team Dream Sistas Registration and Release Form

Agreement

I am requesting membership in Team Dream, a private triathlon club for women-of-color. I understand and acknowledge that the purpose of Team Dream is to promote health and fitness chiefly through the sport of triathlon. I understand and acknowledge that the sport of triathlon is comprised of three disciplines, which are swimming, cycling, and running. I understand and acknowledge that expert coaching sessions, workshops and seminars are provided in each of the disciplines, and that some of these coaching sessions, workshops and seminars may incur additional costs. These costs will be made known to me and these costs are my responsibility. In that Team Dream is a triathlon club, I understand and acknowledge that as a member my season goal is to complete at least one triathlon, that being the Trek Women’s Triathlon Series (TBD), South Shore Triathlon (Aug), and/or Danskin Women’s Triathlon Chicagoland (Jul). All Team Dream members are encouraged to compete in this event unless it is inadvisable for medical/health reasons to do so. If it is determined that I cannot compete I understand that I am expected to be available as a volunteer during the event. Additionally, I understand that it is my responsibility to be aware of the information disseminated to the group via email and that I must provide an email address for that purpose. I hereby grant to you the universal and perpetual right to use, and to grant others the right to use, my actual or simulated likeness, photograph, voice, personal characteristics and other identification in all manner and media whatsoever in, and in connection with, Team Dream and any other productions; provided, however, that the rights granted to you herein shall not permit exercise of these rights as a direct commercial endorsement by me of any product or service (other than Team Dream) without first obtaining my consent. As a member I am also encouraged to compete in other triathlons (both outdoor and indoor), and to make my goals known to the coaches, who are accessible for counsel. In that the sport of triathlon consists of three events, I understand that I am expected to participate in individual road (running) races as well as cycling and swimming events. Team Dream reserves the right to revoke the membership of any member who does not meet the requirements as stated herein, and/or refuse future membership. Membership fees are non-refundable, without exception.

Name

First Name

Last Name

Email Address

Mobile

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Home

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Office

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

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Emergency Contact Full Name

Emergency Contact Number

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Emergency Contact Relationship

Medical History

Please select any of the following medical problems, if they apply.

HYPERTENSION

SEIZURE DISORDER

HEART CONDITION

ASTHMA

Please list any allergies (food, medications or insect stings)

Please list any medications that you are currently taking

Please list any and all medical conditions for which you are being treated

RELEASE FROM LIABILITY

I, the undersigned participant, have either had a physical examination and been given a physician’s permission to participate in the programs of Team Dream or decided to participate without the approval of a physician and do hereby assume all responsibility for my participation in such programs. I acknowledge that I am aware of all risks inherent in triathlon training including possible permanent disability and death and agree to assume all those risks. AS A CONDITION OF MY PARTICIPATION IN THE TEAM DREAM PROGRAM OR ANY ACTIVITIES THERETO, I HEREBY WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSSES OR DAMAGES INCLUDING ALL CLAIMS FOR LOSS OR DAMAGES CAUSED BY NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING: TRI\MASTER’S INC., HOST FACILITIES, OR ANY INDIVIDUALS SUPERVISING THE TEAM DREAM PROGRAM.

Electronic Signature