Run for YOUR life

1
Name* This field is required
First, Last Name
Age
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2
Gender* This field is required
Male
Female
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3
Full Address* This field is requiredCity, State, Zip
Address, City, State, Zip
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Phone Number* This field is required
Area Code
Phone Number
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5
E-mail* This field is required
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6
Media Release Consent * This field is requiredI grant permission to Central Utah Public Health Department to use photographs, video, audio recordings, statements, and/or textual material for use in press releases, newsletters,or other publications, or electronic matter that may be used in conjunction with them now or in the future, whether that use is know to me or unknown. I hereby agree to release and hold harmless Central Utah Public Health Department from and against any claims, damages or liability arising from or related to the use of photographs, video, audio recordings, statements, and/or textual material. I have read this release before signing below, and i fully understand the contents meaning and impact of this release. I am 18 years of age or am the parent or guardian of minor.
First, Last Name: Date (if signing for minor also include name of minor and relation)
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7
SignatureIn consideration of my entry, I release Central Utah Public Health, All sponsors and all others directly or indirectly involved in the event from all right, claims, liability, damages, and/or pain suffered by me while participating in the Run for "YOUR" life 5k Run or Walk. I attest and verify that i am physically fit to participate in this event.
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