RUN FOR FUNDS ENTRY FORM
NAME ______________________________________________________________________
ADDRESS ___________________________________________________________________
CITY, STATE, ZIP _____________________________________________________________
DAY PHONE __________________________
SEX ____ MALE _____ FEMALE AGE ON RACE DAY ____________________
EMAIL ______________________________________________________________________
T-SHIRT: PLEASE CHECK:
ADULT YOUTH
____ SMALL ____ SMALL
____ MEDIUM ____ MEDIUM
____ LARGE ____ LARGE
____ X-LARGE
RACE RELEASE: I know that running a road race is a potentially hazardous activity. I attest and verify that I have full knowledge of the risks involved in the race, that I assume those risks, that I will assume responsibility for and pay my own medical and emergency expenses in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses, and that I am physically fit and sufficiently trained to participate in this race. I assume all the risk associated with running in this event, including but not limited to fall, contact with other runners, the effects of weather, including high heat and/or humidity, traffic and other conditions of the road, all such risk being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I for myself and anyone entitled to act on my behalf, waive and release the Iberia Parish Medical Auxiliary and all sponsors, their representative and successors, from all claims and/or liabilities of all kinds arising out of my participation in this event. I grant permission and release the rights to any photographic material and computer information that the Iberia Parish Medical Auxiliary may wish to release for this event without obligation to me.
____________________________________________________________________________
SIGNATURE OF PARTICIPANT DATE
____________________________________________________________________________
SIGNATURE OF PARENT (if participant is under 18) DATE
Mail registration form and fee to:
Iberia Parish Medical Auxiliary
c/o Mary Kay Snellgrove
PO Box 11036
New Iberia, LA 70562-1036
