MACEM Run to the Rescue 5K Waiver

Frederick Community College

5K Activity Waiver Agreement

Name of Participant*

First NameLast Name

Participant Email*

example@example.com

Participant Phone*

Area CodePhone Number

Participant Birthdate*

m/d/yyyy

Walker or Runner*

Tshirt Size (Adult Unisex)*

Participant Signature*

Clear

Date*

Date

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Area CodePhone Number

Parent or Guardian Name (If Participant is Under 18)

Parent of Guardian Signature(If Participant is Under 18)

Clear

Contact Us

Mid-Atlantic Center for Emergency Management & Public Safety
7932 Opossumtown Pike • Frederick, MD 21702
MACEM@frederick.edu • (301) 624-2854

Frederick Community College (FCC) prohibits discrimination against any person on the basis of age, ancestry, citizenship status, color, creed, ethnicity, gender identity and expression, genetic information, marital status, mental or physical disability, national origin, race, religious affiliation, sex, sexual orientation, or veteran status in its activities, admissions, educational programs, and employment. FCC makes every effort to accommodate individuals with disabilities for College-sponsored events and programs. If you have accommodation needs, call 301-846-2408. To request a sign language interpreter, please call 240-629-7819 or 301-846-2408 (Voice) or email Interpreting@frederick.edu. Sign language interpreters will not be automatically provided for College-sponsored events without a request for services. To guarantee accommodations, requests must be made at least five workdays in advance of a scheduled event.