Last Name:

                  Street Address:

                                    City:

                                  State:

                                      Zip:

                         Day Phone:

                  Evening Phone:

  Date Of Birth (MMDDYY):

                              Gender:    Select One Female Male

                  Email Address:

                Event Category:    Select One Run Walk Walk With Stroller Waddle

                               T Shirt:    Select One Small Medium Large Extra Large

In order to qualify for 4 or more group discount you must register at the same time.  Complete this form and then click register participant.  Click back in the browser or click on add additional participants.  Once you have completed all registrations for the group then you may send the order for billing.

                    Group Name: Required for group discount.

Participant’s WAIVER, RELEASE AND ACKNOWLEDGEMENT (must be signed): I know that running/walking is a potentially hazardous activity. I agree not to enter and run/walk unless I am medically able and properly trained. I agree to abide by any decision of an event organizer relative to my ability o safely complete the run/walk. I assume all risks associated with running/walking in this event including, but not limited to: falls, contact with other participants, the effects of weather, conditions of the course, all risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive the right to sue Run, Walk and Waddle and the Kempe Center, any of its officers, agents, volunteers, assistants or employees any and all sponsor companies, their representatives and successors from all claims or liabilities of any kind arising our of my participation in this event, even though that liability may arise our of negligence or carelessness on the part of persons and entities named in this waiver. I also authorize and consent to use my name or any photographs, videotapes, recordings, media releases and my other record of participation in this event for any publicity or promotional purposes without obligation or liability to me. Entry fee is nonrefundable and nontransferable.

          Agree With Waiver:               Select Yes

Signature (Required For All Participants):              

Signature above must be signed by parent or guardian if under 18

Online Registration Is Now Closed.