2015 Plaza de la Raza Zumbathon Registration Form.

Plaza de la Raza Child Development Services
2015 Zumbathon Registration Form
One registration form is required per participant.
Last Name _______________________________First Name________________________________
Address_____________________________________________________________________________
City___________________________________________________State_____________Zip_________
Phone__________________________________Email_______________________________________
DOB______/______/________Gender___________________________________________________
(Note: Date of birth and gender are optional)
Emergency Contact Name____________________________ Phone_______________________
T-Shirts will be provided to pre-registered participants. Those registering on the event
day will receive shirts on a first-come first-served basis. Available sizes are:
ADULT:
S
M
L
XL
(Circle One)
Payment
___Enclosed is my cash or money order for $_________ payable to Plaza de la Raza
Child Development Services, Inc.
Waiver and Release: I declare that I am participating in the 2015 Plaza de la Raza
Zumbathon, having voluntarily and knowingly assumed ALL RISKS involved in this Special
Event, including but not limited to those further described in this Waiver. The immediate
physical risks and hazards associated with normal, vigorous physical activity include
(but are not limited to) physical discomfort, fatigue, muscular soreness, falls, pulled or
strained muscles, overuse injuries, heat stress, and the rare instance of abnormal
responses of the cardio-respiratory system, including heart arrhythmia, heart attack,
stroke, and sudden death. In consideration for allowing my participation in this Special
Event and intending to be legally bound thereby, I hereby for myself, my heirs,
executors, administrators and assigns, attorneys and representatives, WAIVE AND
RELEASE any and all rights and claims for negligence, injuries, physical or financial
damages or losses that I may incur against all participating agencies involved in the
above stated Special Event, and specifically Plaza de la Raza Child Development
Services, El Rancho Unified School District, and their respective employees, agents,
representatives and attorneys, successors and assigns, regarding any and all activities
connected with my participation in the Special Event .
Plaza de la Raza Child Development Services
2015 Zumbathon Registration Form
I also WAIVE any and all rights or benefits under California’s Workers’ Compensation
laws for any injury incurred as a result of my participation in this event. In addition, I
waive any and all rights or benefits which I may have under section 1542 of the
California Civil Code, which reads:
A general release does not extend to claims which the creditor does not know or
suspect to exist in his or her favor at the time of executing the release, which if known
by him or her must have materially affected his or her settlement with the debtor.
Signature__________________________________________ Date ___________________________
For questions please contact us at zumba@pdlr.org
Send your completed registration form and payment by April 20, 2015 to:
Plaza de la Raza Child Development Services
Attn: Zumba Event
8337 Telegraph Rd., Ste. 300
Pico Rivera, CA 90660