SAUK GET ACTIVE PROGRAM
REGISTRATION FORM
First Name______________________
Address______________________________________________________________
City_____________________________ State___________ Zip________________
Phone____________________________(Day) _______________________(Evening)
E-Mail________________________________________________________________
Last Name__________________________
Registering for:
_______Let’s Get Active Only
_______Step Up to the Challenge
_______Both Programs
In signing this waiver for myself, or as legal guardian for the named entrant (if entrant is under 18 years of age), I
acknowledge that this a potentially hazardous activity and I am participating in it of my own free will and choice. In
signing this form for myself (or for any named participant under the age of 18), I understand and agree to waive and
release Sauk Valley Community College from all claims and liabilities of any kind arising from my participation in
this event. I have read the above waiver and understand its contents.
Signature________________________________________________________________
Signature of Parent or Guardian (if participant is under 18)____________________________
Registration form and fee of $5.00 per person should be returned to:
Sauk Valley Community College
Attn: Nancy Breed
173 IL Rt 2
Dixon, IL 61021
REGISTRATION FORMS AND FEES ARE DUE BY AUGUST 31, 2012.
