Registration and Waiverrelease and Consent Form

Bethany’s Race

5K Run/Walk

April 29, 2017 - Race begins at 9 am

Lamoni High School

Registration and WaiverRelease and Consent Form

Each adult participant must fill out a form and sign the waiver at the bottom. Children 12 and under must be accompanied by a parent. Registration is $10 for each participant, 13 years and older. The race entry fee supports the Bethany Gruich Scholarship Fund. T-shirt is an additional $10. Registration Deadline is April 19, 2017 at 4:00 pm to receive a t-shirt with the 2016 design. Return to Lamoni Community Centeror Lamoni City Hall with payment.

Participant Names: (13 years and older) $10 Race entry fee and $10 t-shirt fee (optional).

Name: ______Adult Shirt Size: S____ M____ L____ XL____ XXL____

Name:______Adult Shirt Size: S____ M____ L____ XL____ XXL____

Name: ______Adult Shirt Size: S____ M____ L____ XL____ XXL____

Children (12 years and younger) No fee

Child ______Age ______

Child ______Age______

Address ______City ______State______Zip______

Phone

In consideration of the acceptance of my/my child’s entry, I for myself or for my child, do hereby release and discharge the organizers of this walk and all other sponsors and organizers of all claims and damages, actions whatsoever in any manner arising out of my/my child’s participation in this event. I attest and verify that I have full knowledge of the risks involved in this event and I am/my child is physically able to participate in this event. Further, I grant full permission to any and all partners of the 5K Race/Walk to use my/my child’s name, photographs, videotapes, or any other record of this event for any legitimate purpose without compensation.

______

Signature Date

·  No Dogs

·  Strollers will be lined up in the back

·  Race begins promptly at 9 am

Total number of registrations: $10 x ______= $______

Total number of T-shirts: $10 x ______= $______

Child 12 years and under (free) x______

Total $______(checks payable to Lamoni Parks and Rec)

Additional Contribution to Bethany Gruich Fund $______(checks payable to Bethany Gruich Scholarship)

Sponsored by: Lamoni Parks and Recreation, Graceland University and Hy-Vee