Sir Kendrick's Smile for Autism 5K RUN/WALK REGISTRATION FORM
Mike Dickens Memorial Park 101 Sunrise Cir Rice, Tx 75155 1-844-223-0144
Name
*
First Name
Middle Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Contact Number
*
Sex
Please Select
Male
Female
N/A
Age on Event Date
*
Shirt Size
*
Please Select
xs
small
medium
large
xlarge
xxlarge
xxxlarge
xxxxlarge
In Case of Emergency
Emergency Contact:
*
First Name
Last Name
Relationship
Contact Number
*
Release and Waiver of Liability - Assumption of Risk and Indemnity Agreement
In consideration of my participation in the 5K Run, I, the undersigned participant, hereby acknowledge and agree to the following:
*
I am fully aware of the risks involved in participating in a 5K Run and voluntarily assume all such risks.
I am physically fit and have no medical conditions that would prevent my participation in the 5K Run.
I agree to comply with all rules and regulations of the 5K Run.
I release, discharge, and hold harmless the organizers of the 5K Run, their officers, directors, employees, volunteers, sponsors, and any other persons or organizations associated with the 5K Run from any and all claims, damages, or injuries, including death, that may arise from my participation in the 5K Run or as a result of my use of any facilities or equipment provided by the 5K Run.
Date
*
-
Month
-
Day
Year
Date
Signature
*
My Products
prev
next
( X )
Registration Fee
Single Person
$
30.00
Quantity
1
2
3
4
5
6
7
8
9
10
Registration Fee
Family of 4
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Additional Shirt
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit Form
Submit Form
Should be Empty: