Last Name: ______________________________ First:____________________________
Date of Birth:_________________________ Sex: M F
Age on 4-28-13:___________________________
City, State, Zip:___________________________________________________________
Shirt Size: S M L XL
I know that running and volunteering to work in races are potentially hazardous activities. I should not run in this race unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely compete in the run. I assume all risks associated with running and volunteering to work in this race. Having read this waiver and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Fordyce on the Cotton Belt Festival, the Fordyce Chamber of Commerce, the City of Fordyce, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in the race even though liability may arise out of negligence or carelessness on the part of persons named in the waiver.
Parent Signature if under 18 years__________________________Date:___________________
Make check payable to: Fordyce on the Cotton Belt Festival.
Mail to: 5K-Fordyce Chamber of Commerce
............PO Box 588
........... Fordyce, AR 71742
Fees: Including t-shirt-Pre-registered $15.00, race day $20.00