Kick it Like Jackson 5K Run

Participant Information
Full Name

First NameLast Name
Age
Gender
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Details
Contact Person

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Payment Information
Method of Payment
Waiver & Release
By checking this box, you are confirming that you have reviewed and understand the following waiver & release.

I confirm that I am in good shape, health, condition, and don't have any medical condition or 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 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.
Participant's Signature

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
Parent/Guardian Signature (If participant is below 18 years old)

Powered by Jotform SignClear
Date

MonthDayYear
Date

My Products

Early Bird INDIVIDUALS Registration Fee Adult$25.00

If you register before October 25

Quantity

Early Bird FAMILY Registration (family of 6 or less)$100.00

If you register before October 25, 2025

Registration Fee INDIVIDUALS$30.00

After October 25, 2025

Quantity

Registration Fee FAMILY$120.00

After October 25, 2025

Make a Donation to the JBF$25.00

Quantity

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Participant Information