LACKAWANNA RIVER CANOE-A-THON 2005

SATURDAY MAY 7, 2005

1. CHOOSE A LAUNCH SITE – Note: Rental canoes are available for the Blakely launch site only.

Experienced Canoeists only: ARCHBALD TO SCRANTON (12 MILE RACE)   Check here_________

Novice Canoeists: BLAKELY TO SCRANTON (8 MILE RACE)  Check here_________

2A. REGISTRATION FEE 2B. RENTAL FEES

$30.00 Individual (s $30.00 Individual (single) $_______ $55.00 Canoe Rental $_______

$60.00 Team (team of two)     $_______ $30.00 Kayak Rental (single) $________

Amount Enclosed (2A+2B) $___________

3. CHOOSE A CATEGORY (Circle One)

TWO MEN

TWO WOMEN

M/F MIXED

KAYAK or SINGLE

YOUTH (14-18)

ADULT/YOUTH

4. REGISTRATION: Print clearly and include Drivers License # if you are renting a canoe.

Name_____________________________________________ Address___________________________________________ Drivers License Number_______________________ Phone______________ Email____________Age_____

Name________________________________________________ Address______________________________________________ Drivers License Number______________________ Phone______________ Email______________Age_____

5. WAIVER-RELEASE: Read and sign to acknowledge agreement.

_{I/We hereby acknowledge that participation in the Lackawanna River Canoe-a-thon will require extreme physical exertion and exposure to dangerous conditions. I/We hereby assume all risk of injury or damage to person or property resulting from or in connection with the use by me of any of the facilities, equipment, or premises of the course or associated areas. Specifically, I recognize that the race sponsors and organizers have little control over road, traffic, or river conditions. I hereby release the LRCA, local municipalities, their agents, officers, employees, representatives and insurers, and agree to defend, indemnify and hold them harmless of and from all claim, demand, action, or cause of action for injury, damage, or loss to person or property asserted by or accruing in favor of me. I certify that I/We are physically fit and have trained sufficiently for this event. If I am renting a canoe, I agree to be held financially responsible for any loss, theft or damage !; incurred to a rental canoe or equipment supplied by the rental company. The within release is signed voluntarily and is binding upon the below signed; his/her heirs, executors, or assigns. Persons under 18 years old must obtain the signature of a parent or guardian in the space provided below.}

Signature__________________________Date__________

Signature_____________________Date____________

By signing this release I acknowledge that I have read the LRCA Canoe-a-thon rules and safety plan and agree to abide by them.

MAIL THIS FORM AND CHECK OR MONEY ORDER PAYABLE TO: LRCA P.O. BOX 368, SCRANTON, PA 18501-0368 (570) 207-7608