In submitting this entry, I, intending to be legally bound for myself, my heirs, executors and administrators, waive, release and forever discharge The Summit, Pepsi, Sheetz, Altoona Mirror, Furrer Beverage, The Respiratory Disease Society, event sponsors, event volunteers and their officers, directors, agents, successors and/or assigns for any and all injuries suffered by me at this event, while traveling to and from the Wallyball Tournament or while participating in the event. I attest and verify that I am physically fit and sufficiently trained for the competition of this event. I understand that I may be photographed and agree to allow my photo, video or film likeness to be used in any legitimate purpose by the aforementioned parties.

A copy of the official registration and financial information may be obtained from the Pennsylvania Department of State by calling (toll-free in Pennsylvania) 1-800-732-0999. Registration does not imply endorsement.

Name: ___________________________________________________________________________

Address: _________________________________________________________________________

City/State: ________________________________________________________________________

Phone (Daytime): ________________________________________ Age: _____

Sex: Male ___ Female ___

Team Name (if applicable): __________________________________________________________

Date: ________________