DECLARATION OF FITNESS AND WAIVER I, _______________________________________, with postal and residence address at _____________________ ______________________ __________hereby confirmand declarethat: 1. I am participating in the MILO ® Little Olympics to be held on _____________________________ _______ at _________________________________ ____,of my own free will, desire, and volition. 2. I hereby represent and warran t that I am physically fit to participate and take part in the MILO ® Little Olympics and have no known illness, physical defect, or adverse medical condition that would render me unfit to participate in the MILO ® Little Olympics. Should I subsequently discover any illness, physic al defect, or adverse medical condition that would render me unfit to participate in the MILO ® Little Olympics, I shall advise the Organizer in writing and I shall accordingly refrain from participating in any event of the MILO ® Little Olympics. Should I qualify, I shall represent my region in the MILO ® Little Olympics National Finals which will be held on _________________ at ______________. 3. I hereby authorize the Organizer and/ or Event Sponsor to use my name, photograph s, videos, and interviews in conne ction with the MILO ® Little Olympics in broadcast and print media, videotapes, etc. without any monetary consideration. 4. I understand that if and when my identity is challenged by the Organizer , it is my responsibility to prove my identity. 5. I acknowledge th at the MILO ® Little Olympics is conducted and managed solely by the organizer. I understand that Nestle Phils., Inc. is the sponsor of the MILO ® Little Olympics but is not involved in the activity’s conduct or organization, nor in the formulation and implementation of the rules governing the Activity. 6. I agree to abide by the decision of the Organizer on any issue relative to my participation in the MILO ® Little Olympics, including but not limited to official calls and the interpretation of rules governing the Activity, and shall accept as final any decision of the Organizer regarding any dispute over such rules or regarding the manner of holding the Activity. 7. I shall hold the Organizer , Publicis-Manila, Inc., PR Agency, Manpower Agency, and the sponsor, Nestle Phils., Inc. free and harmless from any and all claims arising from any accident, damage, injury, illness, death, or loss that I may suffer as a result of my participation in the MILO ® Little Olympics I hereby declare that I have read and understood this Declaration of Fitness and Waiver and that I have executed this document willingly and voluntarily . IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of _____________ , ____ at ________________________________. (Printed Name and Signature) STUDENT I, ___________________, hereby represen t that I am the parent/guardian of _________________ and that I have given my consent for him/her to join and participate in the MILO ® Little Olympics. I hereby certify that my said child/ward is physically, mental ly and psychologically fit to participate in the said MILO ® Little Olympics. In case he/she will qualify, I will allow my child/ward to participate in the MILO ® Little Olympics National Finals which will be held on ______ at _____. __________________________________________ (Parents/Guar dian’s Printed Name and Signature) I, __________________, hereby certify that I have examined _____________ and I find him/her physically fit to participate in the MILO ® Little Olympics. ___________________________________________ (Medical Doctor’s Printed Name and S ignature) We hereby certify under the penalty of perjury that the above entries of data are true and correct and that the above player has complied with the tournament manager rules and guidelines set forth by the Organizing Committee of the MILO ® Little Olympics and is therefore qualified to play in said event. ____________________________________________ (School Head/Team Coach’s Printed Name and Signature) Please submit this form immediately to the Secretariat Office of the Organizer. F i r s t N a m e N a m e o f A t h l e t e : S u r n a m e M . I . B i r t h D a t e : M M / D D / Y Y Y Y G e n d e r : M F / / A g e : C o n t a c t N o . : W e i g h t ( k g s . ) : H e i g h t ( c m s . ) : A d d r e s s : C i t i z e n s h i p : E V E N T E V E N T E V E N T E V E N T T o u r n a m e n t C a t e g o r y : E l e m e n t a r y H i g h S c h o o l D I V I S I O N B O Y S G I R L S D I V I S I O N B O Y S G I R L S D I V I S I O N B O Y S G I R L S D I V I S I O N M I X E D E D U C A T I O N A L I N F O R M A T I O N N a m e o f S c h o o l : A d d r e s s : D e p E d / S c h o o l S t u d e n t N o . ( i f a n y ) R E G I S T R A T I O N F O R M 2 x 2 P h o t o A t h l e t i c s B a d m i n t o n B a s k e t b a l l C h e s s F o o t b a l l G y m n a s t i c s S i p a / S e p a k T a k r a w S w i m m i n g T a b l e T e n n i s T a e k w o n d o T e n n i s V o l l e y b a l l S c r a b b l e ( M i x e d ) L I T T L E C H A M P I O N S , B I G D R E A M S