Feel the Burn Registration

Feel the Burn 5k Run/Walk

Derrick City Volunteer Fire Department
Race Date: August 14th, 2021

Location: 451 Derrick Rd, Derrick City, PA 16727 at the Derrick City Fire Hall.

Start Time: 8:00 AM registration opens. 9:00 AM race start.
Participant Information

Please register every participant separate, thank you.
Full Name *

First Name Last Name
Birthdate *

Month Day Year
Date
Gender *
Email
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Event *

Run Walk Donation
Emergency Contact Details

Please include 2 emergency contacts.
Contact Person 1 *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *
Contact Person 2 *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship *
**IF CHILD REGISTRATION**

I understand that I as the Parent/Legal Guardian must remain on the premises at all times during this event. In the case any medical attention may be required; I am assuming sole responsibility to transport my child for the necessary medical attention.
Payment Information

Secure payment through Square

My Products

Adult Registration Fee $ 30.00

**OVER 12 YEARS** Registration includes race t-shirt.

Quantity Size

Child Registration Fee $ 15.00

**12 YEARS OR UNDER** Registration includes race t-shirt.

Quantity Size

Extra T-Shirt $ 15.00

If you want an extra t-shirt for any reason, please choose this option ON TOP of your registration. Please remember your registration fee includes a t-shirt.

Quantity Size

Enter coupon

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Waiver & Release

Please read and sign
Waiver Questions *

I confirm that I am in good shape, health, and condition. I don't have any medical condition or medical history that will affect my participation in this event I acknowledge that this road race requires physical activity and there are possible risks and danger. I release the road race event organizers for any responsibility in case of an accident, illness, or injury. I confirm that all information in this registration form is accurate and true.
In consideration of submitting this entry for myself for this event, I, intend to be legally bound hereby for myself/child, my heirs, executors and administrators, waive and release any and all rights I have against Derrick City Volunteer Fire Department and all associates of Derrick City Volunteer Fire Department, the Commonwealth of Pennsylvania, the sponsors of this event, the volunteer staff, and any other sponsors and their representatives, successors, and assigns, for any and all injuries suffered by myself or child in this event. My child will participate in this event as an athletic entrant. He/she is physically fit and has sufficiently trained for the competition and their physical condition has been verified by a licensed medical doctor. I further hereby grant permission to the sponsors of this event and any other sponsors to use all information submitted in this application, and my likeness and voice, as well as photographs, video tapes, motion pictures, recording or any other record of this event, including race results, in which I may appear for any legitimate purpose whatsoever including but not limited to pre-race and post-race publicity by publishing to internet sites, in newsletters or newspapers.

My signature verifies I have read, understand and agree to the information above.
Participant's Signature *

Clear
Date Signed *

Month Day Year
Date
Parent/Guardian Signature (If participant is below 18 years old)

Clear
Date

Month Day Year
Date
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Feel the Burn 5k Run/Walk

Participant Information

Emergency Contact Details

Payment Information

Waiver & Release