When: Thursday, October 17 th, 2013 Where: S.T.A.R. Soccer Complex (next to Morgan’s Wonderland on Wurzbach Parkway) Time: 12:30-5:00pm, Lunch served at 11:30am Lunch provided for team members. This form must be completed and sent to: and by COB 5pm, 10/2/13. Team Name: ____________________________________________________________ Team Captain Name: ________________________________ Company: _________________________________________ Address: __________________________________________ City, State and Zip: __________________________________ Phone: ___________________Fax: _____________________ _____________________________________________ Team Players: Print Name: Signature: Spectators are encouraged to attend. Media Olympics Team Cost: $400 for 10 players (lunch provided for all participants) Check or Credit Card accepted. Check payable to: San Antonio Media Alliance or pay online at Mail Care of: Erika Grimm KENS5/SAMA 5400 Fredericksburg Rd, San Antonio, TX The 3rd Annual San Antonio Media Olympics will be one of the most anticipated media events of the year as teams representing dozens of San Antonio advertising mediums come together for an afternoon of fun and philanthropy…and nobody takes the competition seriously… YEAH RIGHT! Hurry, get your team registered TODAY to be a part of the craziest afternoon of the year... The 2013 Media Olympics! Please complete this Team registration form for your 10-person team + 2 alternates. This team can be comprised of 10 Men and/or Women. Must be over 21 years of age. You can recruit anyone to be on your team. Proceeds benefiting San Antonio Media Alliance’s Scholarship Fund. RULES : There are several ways for a team to score points at Media Olympics. Several physical events, One team branding competition (each team member should be outfitted in a team T-shirt that best represents your team name), and Raffle ticket sales. All raffle $$ is due to the registration table by 1pm on the day of the event) Packet Pick Up Party: Wednesday- 6:00pm-7:30pm Urban Taco at 290 E. Basse Rd/Quarry Market near Trader Joe’s. Last Day to Enter: Wednesday- October 2 nd, 2013 COB MEDIA OLYMPICS Team Registration Form Waiver Of Liability to be signed by Team Captain By affixing my signature to this waiver, I understand and agree that neither the Alliance for Women in Media and/or it’s San Antonio Chapter, sponsors of the event, nor STAR Soccer Complex will be, in any way, held liable for damages or injury of any nature during the 2013 Media Olympics. This includes mental or physical injury. I presently waive any and all claims against those parties arising from or out of my participation or attendance at the “Media Olympics” event held at the STAR Soccer Complex, October 17 th I agree to convey this information to each team member participating and by signing this acknowledge their consent to the terms.

Print Name: Signature:Date Waiver Of Liability By affixing my signature to this waiver, I understand and agree that neither the San Antonio Alliance for Women in Media and/or it’s San Antonio Chapter, sponsors of the event, nor STAR Soccer Complex will be, in any way, held liable for damages or injury of any nature during the 2013 Media Olympics. This includes mental or physical injury. I presently waive any and all claims against those parties arising from or out of my participation or attendance at the “Media Olympics” event held at the STAR Soccer Complex, October 17 th I agree to convey this information to each team member participating and by signing this acknowledge their consent to the terms. CIRCLE ONE: Team Member or Alternate Name:______________________________________________________________________ Address:______________________________________________________________ City_________________________________________________________________ State________________ Zip____________________ Address:________________________________________________________ Cell Phone:___________________________________________________________ Emergency Contact Name:________________________________________________________________ Emergency Contact’s Phone Number:_________________________________________________________ 2013 MEDIA OLYMPICS Team Member Waiver