JEREMY WRIGHT
MEMORIAL 5K RUN & 2 MILE WALK
August 15, 2009

Runner Information

* Name

* Address

* City

* State

* Zip

* Phone

* Email Address

* Age

* Gender

Male

Female

Choose Race:

$20 Run with T-Shirt

$10 Run without t-Shirt

$5 Run for children 12 & under

.

$20 Walk with T-Shirt

$10 Walk without T-Shirt

$5 Walk for children 12 & under

Size T-Shirt (if applicable)

Small

Medium

Large

Extra Large

***Registration Fee is NON-REFUNDABLE on all entries***

* WAIVER OF LIABILITY: In consideration of the acceptance of my entry, I for myself, my executors, administrators, and assignees, do hereby release and discharge the Flat Rock Citizens Committee and Volunteer Fire Dep't. and all sponsors for all claims of damage, demands, actions, whatsoever in any manner arising or growing out of participation in this August 9, 2008, Jeremy Wright Memorial 5K Run & 2 Mile Walk. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in this event.

I accept

* Indicates Response Required