2012-06-06_PR_Packet - Laserfiche WebLink

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Name: Address: Telephone Number (H): city (C): Age: Gender: M F State: Zip: Birth Date: / Event: 5K Run IOK Run Wheelchair Fun Run Please make Run registration check payable to: Run for the Roses IOK Roll Rec/Fitness IOK Roll Pro /Racer Please make Roll registration check payable to: Roll for the Roses T Shirt Size: Youth Med Youth L Adult S Adult Med Adult L Adult XL Adult XXL 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 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 verify that I have full knowledge of the event and that I am physically fit and sufficiently trained to participate. Each form must be signed. I have read and agree to the above waiver: Signature Parent of Guardian (if under 18) Tennessen Warning: The information requested on registration form will be used to verify eligibility and determine staff, faculty and equipment needs. Your/ your child's name, age, address, telephone number and health information will be provided to city staff, volunteers, the city manager, insurer and auditor. Al- though you are not legally required to disclose this information, failure to do so will prevent you /your child from participating.