First Name:

     Address:

            City:

          State:

              Zip:

         Phone:

          Email:

       Gender: Select Female Male

  Birth Date:

Age On Event Day:

          Event Option:           Select One 5K 5K Elementary Age 1 Mile With Shirt 1 Mile Without Shirt

                Shirt Size: Select One Youth Small Youth Medium Youth Large Small Medium Large X Large

In consideration of the acceptance of my entry in the Ogden Clinic Shadow Valley Elementary 5K / 1-mile race, I, the undersigned participant, and if less that 18 years of age, my parent or guardian, intending to be legally bound, do hereby for ourselves, and heirs, executors, administrators and assigns, forever waive, release and discharge any and all rights, claims and actions for damages that we or any of us may hereafter accrue to us or any of us, against any and all persons, organizations and entities associated with the event, including but not limited to the Ogden Clinic, Shadow Valley Elementary School, Ogden City, Weber County, any and all sponsors of the event, the state of Utah, volunteers, and individual race organizers, arising out of or in connection with my entry in, travel to, participation in, and returning from the Ogden Clinic Shadow Valley Elementary 5K / 1-mile race. I attest and verify that I am physically fit and sufficiently trained to participate in this event and that I understand that I am responsible for my own safety while participating in this event, and the post-race activities. I also give my permission for the free use of my name and/or pictures in broadcasts, telecasts, newspapers, posters, advertising, etc. I understand that the entry fees are non-refundable.

                   Waiver:           Select Yes

Participant Signature:           (parent or guardian if under the age of 18)

 

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