Run for the American Dream 5K
R E G I S T R A T I O N F O R M
Please complete the following registration form for
each participant and mail with your $25 registration fee postmarked before
Please complete one form for each person (including teams
and families)
First
Name___________________________ Last
Name________________________________
Address
______________________ __City __________________ State____ ZIP_________
Phone
(Day) __________________ (Evening) _____________________Email
:
Age (on
Shirt Size (Circle One) YS
YL S M
L XL XXL
XXXL Participation
q Team
q I’m collecting pledges
q I’m a volunteer
Team Information (each person must
complete if applicable)
Team Name:_________________________
Team leader:_________________________ Phone:________________
Additional Donation Emergency
Contact
I have enclosed an extra $_______as a direct donation to Working Name ________________
Neighborhoods Phone
________________
Money Enclosed:
Registration ($25 Before Race Day $30) $____________
Additional T-Shirts ($12.00 each) $____________
Additional Donation $___________
Total Donation $___________
In
consideration of the acceptance of my entry, I for myself, my executors,
administrators and assignees, do hereby release and forever discharge
officials, administrators, and all sponsors and individuals from all claims of
damage, demands or actions whatsoever in any manner arising or growing out of
my participation in said athletic event.
I attest and verify that I have full knowledge of the risks involved in
this event. I am physically fit and
sufficiently trained to participate in this event. By signing below, I hereby give permission
without compensation to Working In Neighborhoods to
use my likeness in photographs for purposes of promoting the “Run for the
American Dream”.
Signature of Participant
_____________________________________________________________
(Parent signature required if participant is less than 18 years of age)