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MEDICAL HISTORY QUESTIONNAIRE
Help us better understand your disability by briefly answering the following questions. Answer only the
questions you feel comfortable answering.
Please list/explain below
Please explain below.
By signing I acknowledge my understanding that my participation in any Kyle Pease Foundation, Inc. event
and/or any pre- or post-event activities (collectively, the “Event”) involves rigorous physical activity and that it
potentially may be hazardous. I attest and verify that my ability to participate in the Event has been verified by
a licensed medical doctor. I expressly assume all known and unknown risks associated with the Event, including
but not limited to: loss of or damage to my property; injury (including death); accidents; the effects of weather;
and terrain conditions that may vary widely, and that may include uneven and/or slippery surfaces, spectators,
participants, and natural and manmade obstacles (including without limitation, vehicles, security barriers, signs,
cables, mats, and debris on the course). In consideration of my participation in the Event, I, for myself, my heirs,
executors, administrators, personal representatives, successors and assigns, waive any and all rights, claims and
causes of action I have or may have against any Race Organizer that may arise as a result of my participation in
the Event. For these purposes, a “Race Organizer” is any one or more of the following: Kyle Pease Foundation,
Inc. and their affiliates; all governmental agencies representing the territory in which the Event will be held; all
sponsors, agents, vendors, and contractors of or for the Event; medical service providers; and the officers,
directors, employees, representatives, successors and assigns of each of the foregoing. I hereby agree to
indemnify all Race Organizers for all claims and losses (including attorney’s fees and court costs), which may be
brought against any one or more of them by anyone claiming to have been injured or otherwise to have suffered
loss or damage as a result of my participation in the Event.
I further grant full permission to any and all of the foregoing to store, use and/or reproduce my image or likeness
by any audio and/or visual recording technique (including electronic/digital) now in existence or hereafter
invented, for any legitimate purpose, including commercial sales and marketing purposes. I understand and
agree that information about me that is collected by Kyle Pease Foundation, Inc. or the Race Organizers,
including without limitation information on this form and my Event results may be disclosed to third parties for
any legitimate purpose, including commercial sales and marketing purposes, and that it may be subject to redisclosure
by the recipient(s).
I acknowledge and agree to abide by any Official Rules for the Event that may be posted at the Event or on the
Event’s website. I hereby represent and warrant that I am 18 years of age or older or, if applicable, that I am the
parent or legal guardian of the child under the age of 18 years old who I am registering for the Event and that I
have the full power and authority to agree to these terms on behalf of such child, and to bind him/her to these