5K Run/Walk

FEES: Early Registration (by 3/6/2017) $25 / Late Registration $35 / Day of Race $40 *TIME: 9:00am
Location: First Baptist Church, 11 W. Castor, Dexter, MO 63841

Online Registration available at fbcdexter.org/resources

Contact: Matthew Kinder at matthewkbe@gmail.com

Please mail this form and fee to: Marrianne Bruce, PO Box 762, Dexter, MO 63841
Checks should be made to First Baptist Church
Please do not send cash
Forms and cash may be dropped off at First Baptist Church

Name:____________________________________________________________Phone: (______) ______-_______

Address:______________________________________________City/State/Zip____________________________
Email:_______________________________________________Birthdate:_____/______/________ Sex: __M___F

Age On Race Day:_______________________ T-Shirt Size:(Circle One) AS AM AL AXL AXXL

Fee: (Non-refundable, checks payable to First Baptist Church) ____ Early Registration (by 3/6/2017) $25
____ Late Registration $35 ____ Day of Race $40
I, the undersigned participant, on behalf of myself, my heirs, legates and assigns, hereby agree to indemnify, save and hold harmless First Baptist
Church of Dexter and any of their agents, representatives, employees or assigns, for my health, safety or injury and or disability arising out of or
resulting from participation in this program. In the event of an injury and a parent/guardian cannot be reached, I authorize First Baptist Church of
Dexter to obtain medical care. I also authorize any photos taken of myself, the participant, to be used in any promotional materials by First Baptist
Church of Dexter.

Signature (Parents if under 18 years):____________________________________Date:____________________