Run for Broxton 2014

5K Run/Walk ~ 1 Mile Fun Run

Sunday, December 7, 2014

Freestone Park, 1045 E Juniper Road, Gilbert, AZ

Registration Starts @8:00 a.m.

5K Run/Walk starts at 9:00 a.m. ~ 1 Mile Fun Run starts at 9:05 a.m.

Registration Form

Please print out this form, fill in, and mail WITH YOUR CHECK

Make check payable to Run for Broxton

Mail to: Jennifer Feirstein, 3629 E. Phelps Street, Gilbert, AZ  85295

Last Name:­­­­­­­­­­­­­­­­______________________First Name____________________­­­­

Address:_____________________________________________________­­­­

City:___________________________State:______Zip Code:___________

Phone:___________________Email:______________________________

Age on Race Day:___________Birthdate:_________________Gender:____

 

Event: (Please mark one):___5K Run/Walk  __1 Mile Fun Run 

T-Shirt Size ~ (Please circle one)

*T-Shirt only guaranteed if registered prior to 11/15/14*

Adult ~ S      M        L          XL                   Youth ~ Medium

 

Event

Early Entry Fee By November 15

Entry Fee After November 15

Please Check One

Amount

5K Run/Walk

$25.00

$35.00

1 Mile Fun/Run (non-timed)

$15.00

$20.00

Amount Enclosed

Please read the waiver and sign the form. Thank You. All applications MUST be signed to enter this event. No entry accepted without fee. NO REFUNDS.

WAIVER:
In consideration of your acceptance of this entry, I, the undersigned, hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against the StartLine Racing, USAT&F, Town of Gilbert/Freestone Park, Run for Broxton, Batten Disease Support and Research Association, sponsors, coordinating groups, and any individuals associated with the event, and their representatives, successors, officers, agents, and assigns, for any and all injuries sustained and suffered by me during this race. I verify that I am physically fit and have sufficiently trained for competition of this event and my physical condition has been verified by a licensed medical doctor. I will permit the free use of my name and hereby grant full permission to use any photographs, videotapes, motion pictures, recordings or any other record of this event for any legitimate purpose. I understand that the entry fee is non-refundable and numbers are not transferable. I have read the foregoing and certify my agreement by my signature below.

Signature:_________________________________________________________­­__Date:____________

Parent’s Signature (if entrant is a minor)___________________________________Date:____­­­­_________