The Joseph Sams School

Runner #2 Name: *

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Runner #5 Name: *

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Runner #6 Name: *

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Runner #7 Name: *

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Runner #8 Name: *

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Runner #9 Name: *

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Runner #12 Name: *

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Runner #13 Name: *

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Runner #14 Name: *

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Runner #15 Name: *

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Runner #16 Name: *

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Runner #17 Name: *

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Runner #18 Name: *

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Runner #19 Name: *

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Runner #20 Name: *

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WAIVER & RELEASE: I am in proper physical condition to participate in this event. In consideration of acceptance of this entry, I waive any and all claims for myself and my heirs against officials, volunteers, and/or sponsors of Race for a Reason 5K/1Mile/Tot Trot Run event for any injury or illness which may directly or indirectly result from my participation. I grant permission to all of the foregoing to use any photographs, motion pictures, recording or any other record of this event for any legitimate purpose. I understand that radio/tape/CD headsets, dogs or other animals, in-line skates and skateboards are prohibited and that violation of this prohibition will result in disqualification.

*

I have read and agree to the above permission form in its entirety.

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

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Zip Code: *

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Telephone:

Email: *

A receipt will be emailed to this address.