First Name:  

                                    Last Name:  

                                         Address:  

                                                City:  

                                              State:  

                                                  Zip:  

                                             Phone:  

                                              Email:  

Walking Or Running In Honor Of:  

                         Age On Race Day:  

                                            Gender: Select One Male Female
 

                                               Event: Select One 5K Run 5K Walk
 

                                             T-Shirt: Select One Small Medium Large Extra Large
 

                                                  Fee: Select One Adults Seniors 60 And Over Youth 12 And Under

Full Waiver & Release: In consideration for my entry being accepted, I hereby waive and release forever for myself, for my heirs, executors, administrators, any & all claims of actions & suits I may accrue against the Porterville Breakfast Rotary, City of Porterville, County of Tulare, property owners on whose property the race is run, race director, volunteers and any sponsors of this race for any bodily injury, property damage or economic loss, including death, suffered by me while traveling to and from or competing in the Porterville Cancer 5K run or 5K Walk on May 5, 2007 whether from natural hazards, human-made or any other defect or omission or act.

                                            Waiver: Select One Yes I Agree You Must Agree With Waiver In Order To Participate.
 

                                       Signature:  

Parent or Guardian For Minor (I am representing that I have the Authority to sign this release)  sign below

                                        Guardian:

Online Registration Is Now Closed