AMICA MID-SUMMER TRIATHLON & DUATHLON Entry Form
Sunday, July 29, 2012 (8:00AM)
Blue Lake Park, Troutdale, OR
Sprint Distance Tri**:Tri-iT Novice Triathlon:Sprint Distance Du*:Olympic Distance*:


Web site: www.racecenter.com/midsummer
Email: events@racecenter.com

*TRI NorthWest Sprint Distance Championship
*TRI NorthWest Ranked Event (Tri/Du)

Instructions
> Type in your information in the blanks provided.
> Print entry form & SIGN WAIVER (Entry will not be accepted without the signed waiver)
> Make Checks Payable to:
Mid-Summer Triathlon

Mail to:
AA Sports, Ltd.
4836 SW Western Ave
Beaverton, OR 97005


Event (Choose One)

Individual
INDIVIDUAL (entry includes: Tech Shirt, ChampionChip Timing, awards, prizes, food, festivities, and great camaraderie. (TRI NorthWest members deduct $10.00 from entry fees)

Relay - Three Person (EACH PERSON MUST FILL OUT SEPARATE ENTRY FORM & ALL MUST BE MAILED IN TOGETHER)

First Name / MI / Last Name

Street Address


City

State/Province

Zip/Postal Code

Birthdate - mm/dd/yy

Age

Gender

Phone

Email

Division (Individual)


Special Divisions (Applies to Individuals ONLY)

RELAY MUST COMPLETE*
* Division (Combined three ages. If two on a team, take the person who is doing two disciplines and double it)

* Team Name (20 characters or less)

* Teammates Names:

Swimmer (tri)

Runner #1 (du)

Biker

Runner (tri)

Runner #2 (du)

Tech Shirt Size

ChampionChip Number (if applicable - Example - CE12345)

TRI NorthWest Membership # (if applicable) - Members can deduct $10.00 from entry fee

Check#

Amount Enclosed


WAIVER MUST BE READ, SIGNED AND MAILED WITH ENTRY
OFFICIAL WAIVER: I acknowledge that a Multi-Sport Event is an extreme test of a person's physical and mental limits and carries with it the potential for death, series injury, and property loss. I HEREBY ASSUME THE RISKS OF PARTICIPATING IN THIS EVENT. I certify that I am capable of completing all disciplines of the event, and that I am physically fit and that I have sufficiently trained. I agree to abide by the competitive rules. I hereby take the following action for myself, my executors, administrators, heirs, next to kin, successors and assigns, or anyone else who might claim or sue on my behalf, and I hereby waive, release and discharge from any and all claims, losses, or liabilities for death, personal injury, partial or permanent disability, property damage, medical or hospital bills, or theft which may arise out of or relate to my participation in this event. I agree not to sue, and to hold harmless any and all persons, sponsors, volunteers, participants or government agencies for any and all claims or liabilities that I have waived, released or discharges herein. I further agree to return the timing Chip that is been issued to me or to pay a $30 replacement charge. The Entry Fee is Non-Refundable.

Type Full Name


Signature X ___________________________________________________________________
(Signature of Parent or Legal Guardian if participant is under the age of 18)

Date________________________________________