Rotary Club of Petal

1st Annual Rotary Race

Registration Form

Name (please print) __________________________Age on Race Day_____ DOB ___/___/___

Address:________________________________ City/State/Zip_________________

Day Time Phone_______________ Home Phone:______________________

Pre-Registration by mail

And postmarked Nov. 10th

5K Run/Walk: $15

Day of Race: $20

RACE PACKETS

All pre-registration race packets will be available the day of the race, Nov. 15th, by 7:00am.

RUNNERS MUST COMPLETE THE WAIVER AND RELEASE STATEMENT

In consideration of the acceptance of this entry and my registration as a participant in the Rotary 5K Run/Walk, I do hereby waive any and all rights and claims which I, for myself and my heirs, executors, administrators and personal representatives may now or hereinafter have against and do hereby release the Rotary Club of Petal, its members, Rotary International, insert sponsor, and all officials, volunteers and other sponsors of the Rotary Race for any and all injuries, illness, losses or death suffered by me resulting either directly or indirectly from my participation in the Rotary Race 5K Run/Walk.  I fully understand that my participation in this event is completely a voluntary undertaking and that I assume all risk associated with my participation, including, but not limited to, falls, contact with other participants, effects of the weather, traffic and the conditions of the course.  I hereby certify that I am adequately fit and in the proper physical condition to participate in this event and that I am not participating in this event against the advise of a physician nor am I taking medications which would impair my health or ability to participate in this event.  I hereby authorize the use of my name and any photographs, videotapes and other record of my participation in this event for any legitimate purpose by The Rotary Club of Petal.

I acknowledge that I have read and fully understand the above and assume complete responsibility for all risks associated with participation in the Rotary Club of Petal Rotary Race 5K Run/Walk.

___________________________________

PARTICIPANT SIGNATURE

___________________________________

(If participant is under 18, parent or guardian must sign)

Check one: ____Male  ____Female

Adult T-Shirt size (circle one):   S   M   L   XL

Do you wish to receive information about joining Rotary?

(circle one)    Yes      No

Mail Checks and pre-registration to

The Rotary Club of Petal

Attn: 5K Race/ Kelli Phillips

4 Fawn Point

Petal, MS  39465