Form Center

Step One

ALL PROCEEDS BENEFIT THE SPECIAL OLYMPICS
After your form is submitted, you will be redirected to the Special Olympics donation site. In lieu of a registration fee we encourage a $25 donation to our PCSO Torch Run Team. Thank You for your support!
First Name*
Last Name*
Phone Number*
Email Address*
Child's Name (if you are registering a child)
T-Shirt Size (Order by September 22nd to guarantee size)*
Child's T-Shirt Size (Order by September 22nd to guarantee size)
Emergency Contact Information
First Name*
Last Name*
Phone Number*
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Step Two

Assumption of Risk/Liability Release Agreement and Permission Slip MUST READ AND E-SIGN
PCSO Special Olympics Fundraiser
Placer County Dewitt Center
2929 Richardson Drive
October 14, 2023

I, the undersigned, hereby acknowledge that I have voluntarily signed up to participate in the PCSO Special Olympic Fundraiser 5K Fun Run.

I acknowledge that I (or for any minor on whose behalf I am signing this release) willingly and voluntarily assume all risk of harm, including bodily injury, death or property damage as a result of my participation in this activity or of my use of Placer County facilities during the activity, and hereby waive all claims against Placer County, its employees, agents or officers as a result. Furthermore, should I (or any minor on whose behalf I am signing this release) require medical treatment during the activity, I give PCSO Special Olympics Fundraiser agents, employees, and associates express permission to provide the requisite treatment.

I agree that the terms of this release shall serve as a release of any and all legal liability, and as an assumption of risk for myself (or for any minor on whose behalf I am signing this release), my personal representatives, heirs, next of kin, spouse, members of my family, assigns and all other persons.
Electronic Signature Agreement*
By checking this box you agree to the above Assumption of Risk/Liability Release Agreement
1. I agree.
Electronic Signature
Today's Date*
Today's Date
First Name*
Last Name*
Best Contact Number*
As a Parent or Guardian of (enter your child's name below)
Child's First Name
Child's Last Name
I have read and agree to the terms above. I agree that said minor may participate in the PCSO Special Olympics Fundraiser 5K Fun Run activities, and agree that I assume full responsibility for any injuries or damages due to their participation in the activity
Electronic Signature Agreement
By checking this box you agree to the above Assumption of Risk/Liability Release Agreement
1. I agree.
Electronic Signature
Parent or Guardian Name
First Name
Last Name
Parent or Guardian Cell Phone Number
Child's Information
First Name
Last Name
Age
**Important Note**
After submitting, you will be immediately directed to the Special Olympics donation page. Click the red 'Support Us' button to make your donation. In lieu of a registration fee we encourage a $25 donation to our PCSO Torch Run Team. Thank You.

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