Registration And Consent Form

1ST ANNUAL

De&olo Da&llfor Dy&lro hy Sk Run/I MUefun W Why:

To raise funds for Muscular Dystrophy Association, helping to fund research and provide camps and services for people with muscular dystrophy.

When:

Saturday,

May 9th, 2009, 8:00 a.m. Runner/walker check-in and

registration will be held from 7:00 -7:45 a.m.

Where:

DeSoto Senior High School Track, 815 Amvets Drive, DeSoto, MO 63020

The course of the 5k Run will be located on the streets of DeSoto, while the 1 mile Fun walk will be on the track. The streets will be open to vehicles, so please be careful of traffic. Try to stay on the side walk or road shoulder. There will be volunteers to help with traffic control.

Co s t:

$17 postmarked by April 25, $20 postmarked after April 25. Donations are welcome, also. The first 75 registered participants will receive a "DeSoto Dash" t-shirt. Please send the signed waiver along with the bottom of this page.

Awards:

Your age on May 9th, 2009, will determi~e what age group you qualify

for. Medals will be awarded to the top two runners in each age group for each gender. The age groups are as follows: 12 and under, 13-16, 17-20, 21-30,31-40,41-49,50 and up. Trophies will be presented to the top overall male and female runner. Random prize drawings will also be awarded at the event. Please mail thisportiontoJaredMcKeon(5022RemingtonRoad.DeSoto.MO)

along with enclosed fees

1st Annual DeSoto Dash for Dystrophy Name:

_

Address:

_

City/State/Zip: Amount Enclosed: Registration Fee-S,

Phone (evenings):

_ _

_

Age (on 5/9/09):.

Gender (circle): Male

Shirt Size (circle): Youth Adult

_

Female

M L S M L XL

XXL

SE-3 5/07

MUSCULAR DYSTROPHY ASSOCIATION. INC. WAIVER. RELEASE & CONSENT NAME OF EVENT: De Soto Dash for Dystrophy LOCATION:

De Soto, Missouri

DATE(S):

Saturday, May 9, 2009

In consideration

of MUSCULAR

DYSTROPHY

permitting (me)(my child

ASSOCIATION,

INC. ("MDA®n)

, who is under 18) to participate

in the above-named event, I hereby, and for (my)(my child's) heirs, executors, administrators, assigns, and all legal guardians, WAIVE AND RELEASE ANY AND ALL RIGHTS AND CLAIMS OF ANY NATURE, FOUNDED IN WHOLE OR IN PART UPON ANY TYPE OF NEGLIGENCE, that (I)(my child) may have against MDA, its directors, officers, employees, agents,

chapters,

representatives,

assignees,

licensees,

volunteers

and

cooperating

entities,

their

heirs, executors, administrators, successors, and assigns (the "Released

Parties") arising out of or resulting from any and all injuries or damages of any nature, including death, which (I)(my child) may suffer while taking part in the event or any activities connected with the event.

I UNDERSTAND THAT THIS MEANS THAT I AGREE NOT TO

SUE any or all of the Released Parties in connection with the event. Consent also is hereby given to use (my)(my child's) name, picture, portrait, likeness, writings or biographical information (including, if applicable, neuromuscular disease diagnosis), and audiotape and/or videotape recordings and sound or silent motion pictures of (me)(my child) in any media for editorial, educational, promotional, and advertising purposes, for the solicitation of contributions, and for any other purpose in furtherance of the corporate purposes and objectives of MDA. By signing this document, I certify that I have read this document and fully understand it, and that I am not relying on any statements or representations of any Released Party. This document shall be binding upon me, (my)(my child's) heirs, executors, administrators, assigns, and all legal guardians (of my child). Print Name of Participant

Signature of Participant

Date

Home Address. City, State & Zip Code

E-mail

I affirm that I am the parent/legal guardian of authority to authorize his/her participation in the above-referenced MDA event.

(Signature of Parent or legal Guardian if Participant is Under 18)

--'

----

and

Date

-.----------

that

I have

full