BEEMER PLAY DAZE FUN RUN

Registration Form
5 K Run/ 1 Mi Walk
Saturday July 27th, 2013 at 8:30 A.M. (Meet in front of Colonial Haven on Harrison St.) Check-In begins at 8:00 A.M.
Name:

________________________________
Zip: ____________

Address: __________________________________________ City: _________________ State: __________ Phone Number: (

) - ________- _____________ Race: 5K or 1Mi Youth: S M L

Gender: Male or Female T-Shirt Size: S M

L XL XXL

(If you register after July 15th, you are not guaranteed a shirt) Birth Date: ____ / ____ / ________ Age: __________

IF ATHLETE IS UNDER THE AGE OF 18: The signature certifies that my son/daughter has my permission to participate in the Fun Run. The signer has read the foregoing RELEASE AND WAIVER OF LIABILITY (above) and by signing intentionally and voluntarily agrees to its terms and conditions. The signature further certifies that my son/daughter is in good physical condition and is able to safely participate in the Fun Run. I hereby authorize medical treatment for him/her and grand access to my childs medical records as necessary.

The cost for the Fun Run/ Walk is $15.00 (includes T-Shirt if registered in time). Please include with registration form. Make checks payable to Beemer Community Club. Drop form off at First Community Bank or Send to: Jordan or Morgan Schultz P.O. Box 171 Beemer, NE 68716 Signature: ______________________________________ Date: ________