First Name:

            City:

          State:

             Zip:

        Phone:

         Email:

Age On Race Day:

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

              Entry Fee: Select One 5K 1 Mile Fun Run

I hereby, in consideration of myself, my heirs, and administrators, waive all right and claims for damages I may or hereafter have against individuals associated with the Wasenek Weekend 5-K Race or Kid’s Fun Run, their agencies, and representatives, for any injuries suffered by me in this event. I certify that I have full knowledge of the risks involved in this event and that I am physically fit to participate init and have no medical conditions that prevent my participation. I consent to receive medical treatment deemed advisable in the event of injury, accident, or illness during this event. I authorize the use of my name and picture to be used in any promotional materials associated with this event.

    Waiver: Select Yes

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

 

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