Please complete and return this registration form by Monday, October 11, 1999 to ensure that your child's name is listed in the program. Mail the completed form and check in a stamped envelope to: Helen Bean, American Lung Association of Los Angeles County, 5858 Wilshire Blvd., Suite 300, Los Angeles, CA 90036. Please make checks payable to the American Lung Association of Los Angeles County. At least one parent/guardian is expected to accompany the child to the Breath Games?.
Child's Name: ______________________________________ Attending Parent(s)/Guardian(s)Name(s): __________________________ Address: _____________________________________ City _______________ State:_____ Zip _________ Phone (Day) (____)__________ Phone (Eve):(____)__________ Sex: M or F Child's Birth Date:____________ Age on November 7, 1999: _____
My child would like to participate in the following events: T-Shirt (restricted to registered athletes) 1. ____________________________________ Medium 2. ____________________________________ Large 3. ____________________________________ X-LargeI, ______________________, hereby grant to California State University, Northridge and the American Lung Association of Los Angeles County, its constituents and affiliates permission to use of my name and/or my dependent's name, voice, statements, photographs and other reproductions and likenesses. I understand that the above will be used in activities and publications of California State University, Northridge and the American Lung Association of Los Angeles County, its constituents and affiliates and consent there to.
WAIVER AND RELEASE OF LIABILITY FOR INJURY: In allowing (print child's name)____________________________ to participate in the Breath Games(r). I understand and acknowledge that I assume all risk of any kind of injury that my child may receive or sustain as a result of participating in the Breath Games(r). Accordingly, by signing below, I understand that I hereby completely release the American Lung Association of Los Angeles County; the State of California; the Trustees of California State University; California State University, Northridge; and California State University, Northridge Foundation, and each of their agents, representatives, and employees, from liability or responsibility for any and all claims, damages, injuries, losses, or causes of action that may result from or arise out of my child's participation in the Breath Games?.
_______________________________________________ ____________________________________ Parents/Guardian Signature Date ______________________________________________ *Child/Dependent's Name *It is strongly suggested that clearance be obtained from the child's physician prior to participating in the Breath Games?.
When You Can't Breathe, Nothing Else Matters ?
The mission of the American Lung Association of Los Angeles County
is to prevent and eliminate lung disease
and to improve the quality of life and health of those with lung disease.
Your contributions to Christmas Seals? and Chanukah Seals? help make the difference.
For more information on lung health, programs, and special events,
? 1999 American Lung Association of Los Angeles County