Conquer the Hills 2021 – Adult Registration – Farmingville Historical Society

Please complete the form below to register as adult (18 years and older). Once you complete the form and hit SUBMIT, you will be directed to PayPal. You can pay via Paypal, credit card or debit card. The adult fee is $25.

2021 Conquer the Hills Registration - ADULT (18 & Over)

Today's Date *

First Name *

Last Name *

Email Address *

Address *

City *

State *

Zip Code *

Birthdate *

Emergency Contact Name *

Emergency Contact Phone Number *

Select whether you are doing the 5K Run or 2.6K Hike: *

5K Run

2.6K Hike

Event Waiver *

Please read the following statement, and check the box to approve and proceed: In consideration of your accepting this entry, I, intending to be legally bound, hereby waive and release and hold harmless Farmingville Historical Society, Inc., Suffolk County, all sponsors and their representatives, successors and assigns, for any and all liabilities, claims, demands and causes of action whether or not arising in whole or in part out of the negligence of any of the above organizations or individuals. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event and my physical condition has been verified by a licensed Medical Doctor. If approved by a parent or guardian, the parent or guardian agrees to release and hold the above-named organizations and personnel harmless of any claims and rights which may be asserted on behalf of the entrant. Further, I hereby grant permission to any and all of the foregoing to use any photographs, video, recordings or any other record of this event for any purpose whatsoever.

Conquer the Hills 2021 – Adult Registration

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