Registration Form. Please print legibly:
Name: ______________________________________
Address: ___________________________________________
City, State, Zip________________________________
e-mail:______________________________________
DOB: _________________ Age on 9/22/12 __________
Phone #__________________________________________
Emergency # _____________________________________
Male____________ Female_____________
T-Shirt Size: ADULT Sm____ M ____ L____ X-L ____
YOUTH: YM _____ YS _____
____ 5K Runner
____ 5K Racewalker _____1-Mile Fun Run
Early Bird Registration 10K or 5K
Entry Fee: by 9/10 after 9/10
____ 5K (Adults) $ 20 $ 25
____ 5K (15 & under) $ 15 $ 20
____ One-Mile Fun Run $12 $ 14
____ Kids 7 & under with Registered Adult Free (no T-shirt)
____ No T-Shirt Option DEDUCT $2
Entry Fee $___________
Tax Deductible Donation to Bayside Med + $___________
Total Enclosed $___________
Make checks payable to: Bayside Medical Misssions
Mail to: Little Red Hen Productions PO Box 6976, Mobile AL 36660
Waiver:
I know that running a road race is a potentially
hazardous activity that could cause injury or death. I should not enter and run
unless I am medically able and properly trained, and by my signature I certify
that I am medically able to perform this event, am in good health and am
properly trained. I agree to abide by
any decisions of a race official relative to any aspect of my participation in
this event, including but not limited to: falls, contact with other
participants, the effects of the weather, including high heat and/or humidity,
traffic and the conditions of the road, all such risks being known and appreciated
by me. I understand that bicycles, skateboards, baby joggers, roller skates or
blades, animals, and radio headsets are not allowed in the race and I will
abide by these guidelines. Having read this waiver and knowing these facts and
in consideration of your accepting my entry, I for myself and anyone entitled
to act on my behalf, waive and release Bayside Medical Missions, the City of
Daphne, LRH Productions, all sponsors, their representatives and successors
from all claims or liabilities of any kind arising out of my participation in
this event, even though that liability may arise out of negligence or
carelessness on the part of the persons named in this waiver.
Signature:__________________________________________________
Printed name if different from entrant:
__________________________________________________________
Name of your running club:
__________________________________________________________
Race Start address:
Daphne Baptist Church, ball field,
1515 6th Street, Daphne, Al 36526
Located on the corner of College Ave and 6th Street