2015 Walk-Up Registration Form

Eve of Race in person December 4: 5K Run or Free for All Bike Walk Up Registration in person December 6: $40 each Combo 5K Run and Free for All Bike: $60

Race Day Registration in person December 5:

5K Run or Free for All Bike Walk Up Registration in person December 6: 2015 Walk-up $45 each Combo 5K Run and Free for All Bike: Registration Form $65 Run Start – December 5, 2015, 12:00 noon / Bike Start: 12:45 Total Payment Due: Individual Entry Fee $_____ check or money order only, payable to: “Wellness Professionals”

TOTAL:$ One Form PER PERSON, PLEASE! ______Please make check or money order only, payable to: “Wellness Professionals” First Name______M.I. _____ Last Participant Waiver for Race Registration Name______I know that running [volunteering for] a road race is potentially hazardous activity, which could Address______cause injury or death. I will not enter and participate unless I am medically able and properly ______trained, and by my signature, I certify that I am medically able to perform this event, and am in good health, and I am properly trained. I agree to abide by any decision of a race official relative to ______any aspect of my participation in this event, including the right of any official to deny or suspend my City participation for any reason whatsoever. I assume all risks associated with running in this event, ______including but no limited to: falls, contact with other participants or animals, the effects of the ______State_____ Zip weather, including high heat and/or humidity, extreme cold and all forms of precipitation, icy conditions, traffic and the conditions of the road and course, all such risks being known and ______appreciated by me. I understand and will abide by all race rules. Having read this waiver and Phone ______knowing these facts and inconsideration of your accepting my entry, I, for myself and anyone Email entitled to act on my behalf, waive and release the Farmland 5K, Property owner Lewis Rasho, all ______event sponsors, volunteers, partners and their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event, even though that liability may ______arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to all of the foregoing to use my photographs, motion pictures, recordings or any other Gender: (check which) M [ ] F [ ] Age record of this event for any legitimate purpose. I understand there are no refunds or exchanges for as of December 5: ______Date of Birth: any reason. ___ / ___ / ___ Athlete’s Signature: ______Date: ______Signature of Parent/Legal Guardian if Participant is a Minor: ______Race Category:

[ ] 5K Run Only [ ] Free for All Bike Only [ ] Combo 5K Run and Free for All Bike (Bike Type:______REQUIRED)

Optional Section for Team Competition:

I am doing this with a team formed for this event called:______

Walk –up Fees for the 5K Run and/or the Free for All Bike: