Spina Bifida Association of Massachusetts 2009 Falmouth Road Race Team August 09, 2009 In consideration of receiving a guaranteed entry to the 2009 Falmouth Road Race through the Spina Bifida Association of Massachusetts and being accepted in the Falmouth Road Race (the “Event”), I agree to assume all responsibility for any and all risk of damage or injury that may occur to me as a participant, and I hereby, for myself, my heirs, executors, personal representatives, and administrators, release, waive, and discharge any and all rights, claims, causes of action and damages I may have, present or future, whether arising out of, or incident to, my participation in the Event, against The Spina Bifida Association of Massachusetts, The Spina Bifida Association of America, their respective officers, Board members, employees or agents, and against the coordinators and sponsors of the Event. I hereby certify that I am physically fit and have sufficiently trained for competition in the Event and my physical condition has been verified by a licensed physician. I also grant permission for the use of my name and/or picture in any broadcast, photograph or other account of the Event. Print Name: Signature: Date: