First Name:

                  Address:

                        City:

                       State:

                           Zip:

                     Gender: Choose One Male Female

               Birth Date:

                       Phone:

                     Event:        Select One Adult 5K Run Adult 5K Walk Child 1K Fun Run

                   Shirt Size: Choose One Adult Medium Adult Large Adult X Large Child Medium Child Large

LIABILITY WAIVER:

In consideration of your accepting this entry, I, the undersigned, intending to be legally bound hereby for myself, heirs and administrators, waive and release any and all rights and claims for damages I may have against The Village of Louviers, Douglas County Libraries, Douglas County and any other sponsors and their representatives, successors and assigns for any and all injuries suffered by me in said event. I attest and verify that I will participate in this event as a footrace entrant that I am physically fit and have sufficiently trained for the completion of this event and my physical condition has been verified by a licensed Medical Doctor. Further, I hereby grant full permission to any and all of the forgoing to use any photographs, video tapes, motion pictures, recordings or any other record of this event containing my likeness or image for any legitimate purpose with compensation.

  
                                          Waiver: Choose One Yes

                                      Signature:

Parent Or Guardian If Under 18:

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