Firecracker

5K Run/1-Mile Walk
Sunday, June 26th, 2011
Race starts @ 8:00 a.m.
West City Park • Festus
Race starts at Pavilion #12 (Lakeside)

Register online at https://www.raceit.com/register/?event=5077 or

complete this form and return to the Jefferson County Family YMCA
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Complete and return with $15 registration fee
-Please make checks payable to Jefferson County Family YMCA-

Name:____________________________________________ Age:_______ Sex: M F T-Shirt Size: S M L XL XXL

Address:_____________________________________ City:__________________ State: _________Zip: ________

Phone:_____________________________Email:_________________________________ Is this your first 5K? Y N

Waiver: Entry is invalid if not signed. In consideration of the acceptance of this registration entry. I the undersigned, as the entrant and/or parent/legal guardian of all minor children
named on this registration entry, waive any and all claims for myself, my minor child or ward, heirs and successors and assume full and complete responsibility for any injury or accident,
which may occur during my/our participation in the event or while I am on the premises of the event. I hereby release and hold harmless Get Fit Festus (collaboration of the City of Festus,
Jefferson County Family YMCA, Jefferson County Health Department , Jefferson Regional Medical Center) volunteers, sponsors, municipalities, promoters and all other persons and
entities associated with the event, or their agents or employees or otherwise. I will not enter or participate unless medically and properly trained. I assume the risk associated with this
event, included but not limited to fall, contact with participants, the effects or weather, including heat and humidity, the conditions of the road, all such risk being known. I further grant
my permission to use any photographs, videotapes, or other record of this event. I understand that all entries are final with no refunds. I have read the forgoing and certify my agreement
by this signature, and my parent’s/guardian’s if under 18.

Signature:________________________________________________________ Date:___________________
Parent if under 18