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:

__________________________________________________________
(Click picture below to view map course)
Optional registration on line at: www.Active.com
Race Start address:
Daphne Baptist Church, ball field,
1515  6th Street, Daphne, Al 36526
Located on the corner of College Ave and 6th Street