2017 Torch Run - Patient Sign-up Form

JJCCC Participant Registration

How will you participate?
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Participant Contact Information
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Torch Run Waiver: I give permission for my child/children (listed below) to participate in the TORCH RUN - Champions Run for Life to be held Sunday, June 11,2017 at the Shoreline Aquatic Park in Long Beach, California. I, for myself and my child/children, waive any and all claims for damages I or my child/children may have against MemorialCare, Long Beach Memorial, Miller Children's & Women’s Hospital Long Beach, Memorial Medical Center Foundation, the Jonathan Jaques Children's Cancer Center, the City of Long Beach, and any individual associated with the above for any and all injuries that I or my child/children might sustain in this event. I accept full responsibility for my child/children, and attest that my child/children, although he or she may be known to be under a physician's care, is physically fit to participate. My designate or I will be present with my child/children at the event. I will additionally permit the free use of my child/children's names and our pictures in broadcasts, telecasts, print, etc.
I agree to the above waiver:
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Additional T-Shirts
CHILDREN'S T-SHIRTS:
Place the quantity of CHILDREN'S size shirts desired next to the size below. There is a suggested $10 donation per shirt. This is in ADDITION to the t-shirt for the patient.
ADULT T-SHIRTS:
Place the quantity of ADULT size shirts desired next to the size below. There is a suggested $10 donation per shirt.