First Name:

                   Address:

                         City:

                        State:

                            Zip:

                     Gender: Choose One Male Female

  Age On Event Day:

                       Phone:

                        Email:

                  Distance:   Select One 5K 10K

                       Event:   Select One Run Walk

In consideration of this entry, being accepted, I hereby for heirs, executers, administrators and myself waive and release any claims that I may have against the City of Bonifacius or any of the sponsors involved in the 5K Fun Walk/Run. I certify that I am physically able to participate in this event.                                                            

                                         Waiver: Choose One Yes

                                      Signature:

Parent Or Guardian If Under 18:

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