2023 Inland Empire Senior Games Registration Form Online Registration: Home | ActiveNet - Online Recreation Activities (activecommunities.com) | Activity | Seniors
or mail completed form with payment to Attn: Inland Empire Senior Games 600 West 5th Street, San Bernardino, CA 92410
Complete all information (Please print clearly) and please sign waiver. Questions: Seniors@sbcity.org or call (909) 384 - 5430
Last Name__________________________ First Name____________________________
Address __________________________________________________________________
City, State, Zip _________________________Telephone (
) _____________________
E - mail __________________________________________ Gender(M/F)_____________
D.O.B (mm/dd/yyyy) _____________________ (Must be 50 years of age by Dec. 31, 2023)
Circle T - Shirt Size: Small
Medium
Large
X - Large
2X - Large
3X - Large
Emergency Contact Information
Print Name ____________________________________________________________
Relationship ___________________________________________________________
Telephone ( ) _________________________________________________________
WAIVER must be signed and mailed with registration. PHOTO AND FILM WAIVER: I hereby grant full permission to the organization, their agents, employees and representatives to use my name, voice, and/or picture or film in any broadcast, telecast, advertising, promotion or other use in relation to the City of San Bernardino Inland Empire Senior Games . LIABILITY WAIVER: I, the undersigned participant, hereby agree to indemnify and hold harmless the City of San Bernardino Inland Empire Senior Games and the organizers of the City of San Bernardino Inland Empire Senior Games , hereinafter sometimes referred to as sponsors, their agents, employees, and representatives and assigns, from any and all actions or claims of whatsoever kind of nature which I or my representatives or assigns may have or at any time in the future have due to any injury or property damage arising out of my participation in the City of San Bernardino Inland Empire Senior Games . I understand and agree that any dispute over injury or property damage caused by myself or another participant must be settled between the individuals. I warrant and represent to the organizers that I have prepared myself for the event(s) which I have entered by practicing the same prior to my participation. I warrant and represent that I am in good physical health and condition, am physically able to compete in the event(s), and know of no physical restriction whatsoever which would prohibit my participation in the City of San Bernardino Inland Empire Senior Games . I have been advised by the organizers that it would be in my best interest to consult a physician prior to my preparation for and participation in this event. I recognize and understand that the preparation and competition may necessitate strenuous physical activity and could possibly activate an unrecognized pre - existing condition which I may have, thereby resulting in serious or life - threatening physical harm to me. The organizers have my permission to have a physician treat me during my participation in the City of San Bernardino Inland Empire Senior Games .
Signature ______________________________________________________ Date ____________________
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