RoadDawg5K
Registration Form and Release

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Last Name First Name

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Street Address Apt. #

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City State Zip Code

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Phone Number Age Birth Date

Gender (circle one): M F

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Email Address

RELEASE: In consideration of the acceptance of this entry to the RoadDawg5K Run/Walk, I waive all claims for myself, my heirs and assigns against all sponsors, promoters, event officials and all others associated with the organization and facilitation of this event for any injury and/or illness which results from my participation. I further state that I am in the proper physical condition to participate in this event. I also authorize the use of my name and/or photograph taken at this event for use in any promotion or news media release without compensation.

SIGNATURE: ______________________________________ DATE: ___________