AMENIA FIRE COMPANY
5K RACE, FUN RUN AND WALK
SUNDAY, MAY 17, 2015
REGISTRATION/ RELEASE FORM – Participants can bring their form with them the morning of the race.
(Please Print)
FIRST NAME: LAST NAME:
EMAIL:
GENDER: M F DATE OF BIRTH:
ADDRESS:
CITY/TOWN: STATE: ZIP:__________________
Yes, I would be interested in participating in a 10K Race
I , recognize that participating in the 5k RUN/WALK does have certain hazards and risks involved. I recognize the risks that are involved and release the AMENIA FIRE COMPANY NO. 1 from all liability, in the event of any personal injuries or harm that may occur to me while participating in this activity on MAY 17, 2015
SIGNATURE: DATE: _________________________________________________________________
PARENT SIGNATURE (if a Minor): ____________________________________________DATE: ___________________________
*OFFICIAL USE ONLY BELOW THIS LINE*
Participant Bib Number _________________ Paid $35.00 Registration fee _______________________________________________
