Breaking Barriers 5K Sign Up Form
Puzzles Love Autism Foundation
Race Date:
April 5,
2025
Location: 555 Ledwith Ave Haines City, Fl 33844
Time: 7:00AM
Participant Information
Full Name
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Day
Year
Date
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Adult (18 years and up)
$35.00
$
35.00
Quantity
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Teens(13y @ 17y)& Seniors)
$25.00
$
25.00
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Kids 12 & under
Free
$
Free
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Medals will be awarded to all individuals who cross the finish line
Free
$
Free
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Credit Card
Waiver & Release
Type a question
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, sponsor's and the City of Haines City for any responsibility in case of an accident, illness, or injury.
I confirm that all information in this registration form is accurate and true.
Participant's Signature
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Parent/Guardian Signature (If participant is below 18 years old)
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