Press – Farmingville Historical Society

COVID - Conquer the Hills Registration - FAMILY RUN

Primary Person's First Name *

First

Primary Person's Last Name *

Last

Primary Person's Address *

Primary Person's Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Person's Phone *

Primary Person's Email *

Person #2 - First & Last Name

Person #3 First & Last Name

Person # 4 First and Last Name

Are you planning on running or hiking?

Hike

Run

Please read and approve the 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.