5k Registration Form - Home Of Grace For Women printable pdf download

Home of Grace for Women

5K Race/Fun Walk

Registration & Liability Wavier Form

Each participant/participant guardian must sign this form

Name: ______________________________________________ Circle Age Group on Race Day:

Address: ____________________________________________ Under 12

13 – 17

18+

City, State Zip: _______________________________________ T-shirt size:

E-mail: ______________________________________________ T-shirts are adult sizes---Available to first 150

Location: Race will begin and end at Steel Creek Lodge – Satsuma, AL

Date: Saturday, November 24, 2012 RAIN OR SHINE

Time: 6:30-7:30 am Registration 8:00 am 5k Race Start

Registration: $20.00-Pre-register $25.00-registrants day of the race

12 $ under $10 Pre-register $15 – registrants day of the race

RELEASE OF LIABILITY (Adult)

Waiver: In consideration of the acceptance of this entry I waive all claims for myself and my heirs against the sponsors, cooperating and

coordinating groups and any individuals associated with this event and will hold them harmless for any and all injuries which may result from my

participation. I hereby give my permission to the media to use my name and photograph in the newspaper, broadcast, telecast of this event

without limitation or obligation. I certify that I am physically fit for this event and understand the risks involved by participating in this event.

_________________________________

_______________________

Signature

Date

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PARENT / GUARDIAN CONSENT FORM AND LIABILITY WAIVER

Participant name: _______________________________ Birth Date: _______________ Sex: ______

Parent/Guardian Name: ______________________________ Home Phone: _____________________

I,________________________________ , grant permission for my child,____________________________ , to participate in the Home of Grace

for Women 5k Race/Fun Walk. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named

minor (“participant”). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the

Home of Grace for Women, its officers, directors and agents, or representatives associated with the event, arising from or in connection with

my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to

compensate the Home of Grace for Women, its officers, directors and agents, or representatives associated with the activity for reasonable

attorney’s fees and expenses arising in connection therewith.

Medical Matters: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of

my child.

__________________________________

___________________________

Signature

Date

Please make checks payable to: Home of Grace for Women Alumni

Please return Registration & Liability Waiver Form to: Home of Grace 394 Aldock Rd. Eight Mile, AL 36613

5k Registration Form - Home Of Grace For Women