| May 9, 2010 at 9:00 am |
| “Run for “Her” Life” |
Registration Form (One form per person)
| Please make checks payable to Randolph County United Way & mail both the form and the check to: |
| Moberly Radiology & Imaging 1509 Union Avenue P.O. Box 188 Moberly, MO 65270 |
Phone 660-263-8986
Fax 660-263-8993
Name: ______________________________________________ Birth date __________________________
Address: _______________________________________________________________________________
Phone: _______________________________________ E-mail address: ____________________________
Please check all appropriate answers:
Gender (circle): Male / Female
Adult T-Shirt Size (check one): ____Small ____Medium ____Large ____X-Large ____XX-Large
Additional shirts (number) $10 _______ XL or Larger $12 _______
_______ I am a walker _______ I am a runner ______ I am a Survivor
_______ I would like to offer an additional donation of $_____________for this cause.
_______ I am unable to attend the event but would like to participate as a Phantom Walker or Runner.
Enclosed is my donation for $_______________.
Enclosed is my donation for $_______________.
Release & Waiver
I know that participating in a walk/road race is a potentially hazardous activity. I should not enter and walk/run unless I am medically able and properly
trained. I agree to abide by any decision of race official relative to my ability to safely complete the event. I assume all risks associated with participating
in this event including, but not limited to falls, contact with other participants, the effects of weather, including high heat, traffic and the conditions of the
road, all risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of accepting my entry, I, for
myself and anyone entitled to act on my behalf waive and release Moberly Radiology & Imaging and all of their sponsors, co-sponsors, their
representatives and successors from all claims or liabilities of any kind arising out of my participating even though said liability may arise out of my
negligence or carelessness on the part of the persons named in this waiver. I grant permission for all of the foregoing to use any photographs, motion
pictures, recordings or any other record of this event for any legitimate purpose.
trained. I agree to abide by any decision of race official relative to my ability to safely complete the event. I assume all risks associated with participating
in this event including, but not limited to falls, contact with other participants, the effects of weather, including high heat, traffic and the conditions of the
road, all risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of accepting my entry, I, for
myself and anyone entitled to act on my behalf waive and release Moberly Radiology & Imaging and all of their sponsors, co-sponsors, their
representatives and successors from all claims or liabilities of any kind arising out of my participating even though said liability may arise out of my
negligence or carelessness on the part of the persons named in this waiver. I grant permission for all of the foregoing to use any photographs, motion
pictures, recordings or any other record of this event for any legitimate purpose.
ENTRIES CANNOT BE ACCEPTED WITHOUT A VALID SIGNATURE!
Signature & Date: __________________________________________________________
Signature of Parent or Guardian (if under age 18):_________________________________
Emergency Contact & Phone Number: _________________________________________
Questions can be answered by email or phone at:
Mother's Day 5k Run/Walk
| Join us on our Facebook Page Mother's Day 5K Run/Walk "Run for Her Life" |
Youth T-Shirt Size (check one): ____Medium ____Large ____X-Large
| Silent auction held May 8th from 2-4 pm and May 9th 7:30 am to event end. |
| Moberly Radiology & Imaging |
|
| T-shirt pickup/Check-in May 8th 2-4 pm and May 9 from 7:30 to 8:30 |
