S.O.C.K. – IT Dance Marathon 334 Buckeye Hollow Road Princeton, WV 24739 304.320.8619 www.facebook.com/SOCKitDanceMarathon
S.O.C.K. –IT Dance Marathon Application About us: The mission of the Students Optimistic for Curing Kids (S.O.C.K. – IT) Dance Marathon is to help knock out childhood cancer by raising awareness and providing emotional and financial support to the children and families who are affected by this disease. Our sole beneficiary is the Emma’s Touch Foundation in Princeton, WV. About the Event: S.O.C.K. - IT is holding a Dance Marathon on March 7 - 8, 2013 at the Mercer County 4-H Camp. On Friday, registration will start at 7pm and the Dance Marathon will start at 8pm. During this event dancers will be required to stay standing and awake for 24 hours. The money we raise will give financial assistance to families who have children suffering from cancer. How You Can Participate: You can be a “dancer” in our dance marathon! Here are the requirements for you to be a dancer: Be 18 years old or older by March 7, 2014 Fill out the application and submit it as soon as possible o There are only 75 dancer slots available o If you submit the application by February 14th then you are guaranteed a t-shirt for the Dance Marathon o If submitted after February 14th your shirt may have to be mailed Collect/give a minimum of a $100 donation (must be submitted with application) o You can ask friends, family, etc. to help contribute to your donation o All checks must be made payable to “Emma’s Touch” with “S.O.C.K.” noted on the memo line Note: Although we have set a $100 donation to participate we encourage you to raise as much as you can for this worthwhile cause. Contact Information: If you have any questions, you can contact Jordan Pruett, Event Coordinator, at 304.320.8619 or
[email protected]. Submit your application and donation to S.O.C.K – IT Dance Marathon, 334 Buckeye Hollow Road, Princeton, WV 24739.
S.O.C.K. –IT Dance Marathon Application PERSONAL INFORMATION:
EMERGENCY INFORMATION:
Name:____________________________________
In case of an emergency, who should we contact? Name:____________________________________
Address:__________________________________ Phone:____________________________________ ___________________________________ Relation to you:_____________________________ ___________________________________
Email:____________________________________
Phone:____________________________________
The closest hospital is Princeton Community Hospital in Princeton, WV – approximately 7 minutes away from the event location. In case of an emergency, would you like emergency responders to transport you to Princeton Community Hospital? YES
NO
Who will be picking you up on Saturday, March 8 at 8pm (the end of the event)?
If NO, where would you like to be transported?
Name:____________________________________
__________________________________________
Their Phone:_______________________________
Are you allergic to anything? __________________ __________________________________________
Please write two songs that you would like to hear during the event (keep in mind that this is an event that will have young children and their families attending): __________________________________________ __________________________________________
__________________________________________
Do you have insurance?______________________ Insurer:___________________________________ Policy Number:_____________________________
What is your T-Shirt size? ____________________ Address:__________________________________ How much is your donation? _________________
__________________________________________
Note: Please make sure all checks are made payable to “Emma’s Touch” with “S.O.C.K.” designated on the memo line.
__________________________________________
For guaranteed t-shirt please submit by February 14, 2014. Forms submitted after will have t-shirt mailed.
Phone:____________________________________
Signature: _________________________________ Date:_____________________________________
S.O.C.K. –IT Dance Marathon Application
S.O.C.K. – IT Dance Marathon Activity Waiver In consideration of this entry being accepted, I hereby, for myself, heirs, executives and administrators, waive and release all claims and causes of action I have against the EMMA’S TOUCH FOUNDATION and STUDENTS OPTIMISTIC FOR CURING KIDS. As well as release any other sponsor or provider of services at the S.O.C.K. – IT Dance Marathon, their officers, directors, employees, agents, and volunteers (hereinafter “Releasees”) from any and all liability to me, my personal representatives, heirs or assigns, for any and all loss or damage on account of any injury to my person or property or resulting in my death arising out of or related in any to my participation in the S.O.C.K. – IT Dance Marathon. I expressly release Releasees from any injuries and/or damages that I may suffer as a participant in the S.O.C.K. – IT Dance Marathon, whether caused by active or passive, ordinary or gross negligence. I further agree to indemnify and hold harmless Releasees from any and all claims, demands or liability in breach or violation of the terms of the Release. I certify I am physically able to participate in the event. I grant permission to Releasees to use my name and likeness in any photographic, videographic, electronic, or other record of the S.O.C.K. – IT Dance Marathon. This Release is intended to be as broad and inclusive as permitted under West Virginia or federal law. If any portion or provision of this Release is held to be invalid, I agree that the balance of the Release shall continue in full force and effect. I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THIS IS A RELEASE OF LIABILITY AND I KNOW THAT MY SIGNING THIS MAY AFFECT MY LEGAL RIGHTS. I HAVE SIGNED THIS RELEASE OF MY OWN FREE WILL. I AM AT LEAST 18 YEARS OF AGE. I HAVE PERSONAL KNOWLEDGE OF THE FACTS STATED HEREIN AND I REPRESENT THAT THEY ARE TRUE AND CORRECT.
_____________________________________________________ Name of Participant
__________________ Date of Birth
_____________________________________________________ Signature of Participant
__________________ Date
__________________________________________________________________________________________________ Participant Residence Address City State Zip Code
