February 5th 2011 in Wickham Park @ 7:30

Participants name: ______________________ Age: ______________ Gender: M F Shirt Size: S M L XL Phone number: (___) __ __ __ __ __ __ __ Email: _______________

$12 before January 29th and $16 on race day
I, the undersigned, in consideration of acceptance of the entry and registration as participant of the 5k Family Fun Run hold harmless and waive any and all claims which I and my heirs or assigns may now or hereafter have against the sponsors of 5k Family Fun Run, and all of the officials which may indirectly or directly result from my participation in this event. I further warrant and represent that I am in proper physical condition to participate in this event and am not participating in this event against physician’s advice nor am I taking medication which would impair my health or ability to participate in this event.

Signature of Parent or Guardian: _________________________________________________________
(if participate is under the age of 18)

Signature of Participant: __________________________________________________________________

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