Form Type: 
Please complete separate forms for each individual per event.
Event Type:        5k Run    5k Walk    KidzRun 5-7   KidzRun 8-11
Date:       Saturday, October 10, 2009
PARTICIPANT - GENERAL INFORMATION
Full Name:
First    Middle    Last
Address:
  Apt.
City:
State:
ZIP Code:
Mobile:
-
Home Telephone:
 -
Email:
Birthdate:
- -
Male    Female
 Age on Race Day (under 18 yrs.)

 
PARTICIPANT - DETAILED INFORMATION
Shirt Size: 
Additional Shirts:
 x $10.00 =

WAIVER: I know that running or walking a race is potentially hazardous and I should not enter unless I am medically able and properly trained. I assume all risk associated with this event including but not limited to: falls, contact with other people, weather, traffic, and road conditions, all risks being known and appreciated by me. Having read this waiver and knowing these facts. I, myself and anyone else entitled to act on my behalf waive and release the 5K race, run, walk organizers, sponsors ,walk/run officials, volunteers, local and state police including any and all of their agents, employees, assigns, representatives and successors from all claims or liabilities of any kind arising out of my entry or participation in this event. I attest that I am physically fit and sufficiently trained for this event. I agree to abide by any decisions of the event officials relative to my ability to safely complete the event. I hereby allow the uncompensated use of my name and likeness in any way the event directors see fit. Applicants for minors accepted only with a parent or guardian signature.

Signature (Parent or legal guardian if under 18 years old):          Date:

 
METHOD OF PAYMENT
Agreement: I agree to pay the amount selected below in USD. By entering my initials in this box, I authorize this transaction.
Payment:
Charge Amount:
Card Type:
Name on Card:
Card Number:
Card Security Code (CSC):
Expiry Date: Month Year



Entry Fees are Non-Refundable and Non-Transferable.
All donations are tax deductible.