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<br /> One Form Per Participant Please Print
<br /> 19M 2
<br /> Name (last name first) Age Sex: M F
<br /> Address -------------------------- City----------____-- State ——Zip
<br /> Telephone Number h
<br /> --- --- ---- (w) ------------ Birth Date -- -- ----
<br /> Event: ❑ 5K Run ❑ 10K Run ❑ Wheelchair ❑ Fun Run Please snake Run registration check payable to:Run for the Doses
<br /> ❑ 10K Roll Rec/Fitness ❑ 10K Roll Pro/Racer Please make Roll registration check payable to:Rollfor the Roses
<br /> T-Shirt Size: Youth Med Youth L Adult S Adult Med Adult L Adult XL Adult XXL
<br /> ChampionChip® Number * If Participant has one, Roll for the Roses Participants only----
<br /> Waiver:Knowingly and at my own risk,I hereby apply to enter an athletic contest,and do hereby waive and release any and all claims for damages that I may incur as
<br /> a direct or indirect result of my participation in this event against the sponsors,coordinating groups,and any individuals associated with the event for said injuries.I
<br /> verify that I have full knowledge of the event and that I am physically fit and sufficiently trained to participate.
<br /> Each form must be signed. I have read and agree to the above waiver:
<br /> Signature Parent of Guardian (if under 18)
<br /> Tennessee Warning:The information requested on registration form will be used to verify eligibility and determine staff,faculty and equipment needs.Your/your
<br /> child's name,age,address,telephone number and health information will be provided to city staff,volunteers,the city manager,insurer and auditor.Although you are
<br /> not legally required to disclose this information,failure to do so will prevent you/your child from participating.
<br />
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