Mosaic Registration

Email: *

ATTESTATION: I attest and verify that I am fully aware of the physical risk of injury or death in participating in this event and voluntarily agree to accept full responsibility and legal liability for the same, that I am fit and have trained sufficiently for this event. I am also aware that the weather conditions on June 15, 2024 may be unpredictable thus posing an increased physical risk. By submitting this entry, I acknowledge having read and agreed to this waiver, release indemnification and attestation. *

I Agree

Entry type *

Individual ( I am participating on my own)

Team (I am participating with a team)

Media Consent: I consent to the free use of my name and picture on broadcasts, telecasts, and the press as they pertain to the Mosaic Fun Run event. I permit the event directors, the sponsors and the charity free use of my name, voice and picture in any broadcast, advertising, promotion or other account of the event. I consent to the collection of my personal information on this form and to any photographs and video recordings of me during the event. *

Yes

No

RELEASE: I, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE, AND FOREVER DISCHARGE, the Bruce Grey Mentorship, the Volunteer Team, the private landowners, the County of Grey, the Municipality of West Grey, the Durham Conservation area and all other associations, sanctioning bodies, and sponsoring companies, and all their respective directors and officers, agents, officials, servants, contractors, representatives, successors and assigns OF ALL AND FROM ALL claims, demands, damages, costs, expenses, actions and causes of action, whether in law or equity, in respect of death, injury, loss or damage to my person or property HOWSOEVER CAUSED, arising or to arise by reason of my participation in the said event, whether as a spectator, participant, volunteer, or otherwise; whether prior to, during or subsequent to the event AND NOTWITHSTANDING that same may have been contributed to or occasioned by the negligence of any of the aforesaid. *

I Agree

Age *

Name of registering Adult: *

PREAMBLE: All payment is due at time of registration. Cancellation prior to June 9 will receive 100% refund, after which a 25% charge will apply. First 100 registrants will receive a complementary event T-Shirt. Pledge forms and donations are due on race day **Prizes will be awarded for Top Individual Adult & Youth and Top Team. *

I understand

PREAMBLE: All payment is due at time of registration. Cancellation prior to June 9 will receive 100% refund, after which a 25% charge will apply. First 100 registrants will receive a complementary event T-Shirt. Pledge forms and donations are due on race day **Prizes will be awarded for Top Individual Adult & Youth and Top Team. *

I understand

RELEASE: I, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE, AND FOREVER DISCHARGE, the Bruce Grey Mentorship, the Volunteer Team, the private landowners, the County of Grey, the Municipality of West Grey, the Durham Conservation area and all other associations, sanctioning bodies, and sponsoring companies, and all their respective directors and officers, agents, officials, servants, contractors, representatives, successors and assigns OF ALL AND FROM ALL claims, demands, damages, costs, expenses, actions and causes of action, whether in law or equity, in respect of death, injury, loss or damage to my person or property HOWSOEVER CAUSED, arising or to arise by reason of my participation in the said event, whether as a spectator, participant, volunteer, or otherwise; whether prior to, during or subsequent to the event AND NOTWITHSTANDING that same may have been contributed to or occasioned by the negligence of any of the aforesaid. *

I Agree

Phone *

Email: *

****************************************MOSAIC FUN RUN ********************

UNDER 18 PARENTAL SIGN OFF. I the parent/guardian of the above registered, consent to my child's participation in this event. I attest that I have read and understood, and agree to the above waiver and release.

Date and time *

FAMILY MEMBERS: Please list all other family Members full names/Ages *

****************************************MOSAIC FUN RUN ********************

Total Entry Fee to be paid *

Choose 1 *

$35 Adult Entry

$20 Youth Entry

Media Consent: I consent to the free use of my name and picture on broadcasts, telecasts, and the press as they pertain to the Mosaic Fun Run event. I permit the event directors, the sponsors and the charity free use of my name, voice and picture in any broadcast, advertising, promotion or other account of the event. I consent to the collection of my personal information on this form and to any photographs and video recordings of me during the event. *

Yes

No

AGREEMENT: I the undersigned, attest that the I have read and understood the above waiver and sign this agreement on behalf of myself and my family members. *

ATTESTATION: I attest and verify that I am fully aware of the physical risk of injury or death in participating in this event and voluntarily agree to accept full responsibility and legal liability for the same, that I am fit and have trained sufficiently for this event. I am also aware that the weather conditions on June 15, 2024 may be unpredictable thus posing an increased physical risk. By submitting this entry, I acknowledge having read and agreed to this waiver, release indemnification and attestation. *

I Agree

Age *

Total Entry Fee to be paid *

TEAM NAME (if registering with a team):

Congratulations! You are part of the first 100 participants. Please choose your T-Shirt sizes for each family member. Youth x-small (2-4), Youth small (6-8), Youth Medium (10-12), Youth Large (14-16), Youth X-Large (18-20), Adult small, Adult medium, Adult large, Adult x-large, Adult 2XL

Phone *

Entry type *

Family (We are participating individually)

Family (We are participating as a team)

AGREEMENT: I the undersigned, attest that the I have read and understood the above waiver and sign my agreement on my behalf. *

Choose 1 *

$90 Family Entry (4 members of same household)

Additional members $10 each

Name: *

TEAM NAME (if you will be participating as a team):