REGISTRATION FORM
(Please print, fill out and mail to MCA.)
(Please complete one form for each participant.)
Name___________________________________________________
Age (as of Feb. 27, 2010):________________
Date of Birth:__________________________
Sex: ______Male _____Female
Address:________________________________________________
City:___________________________________________________
State:_______ Zip:_______________
Day Phone:_____________________________
E-Mail________________________________
PACKET PICK-UP
:
Saturday, Feb. 27, 2010 - 6:30 - 8:00 am
I AM PARTICIPATING IN THE:
____5K Run ____Family Walk ____Kid’s Walk
MY T-SHIRT SIZE IS (please circle one):
Adult: S M L XL XXL
Child: XS(2-4) S(6-8) M(10-12) L(14-16)
EVENT COST:
Individual: $20.00 before race day $____________
$25.00 race day $____________
$10.00 Kids (3 -12) no deadline $____________
Families: $50.00 (2 adults & kids under 12) $____________
HS Teams: $100.00 (up to 7 team participants) $____________
Additional Donation to Mount Carmel Academy: $____________
TOTAL AMOUNT DUE...$_____________
Please make checks payable to Mount Carmel Academy.
In consideration of my right to participate in the MCA Garden Villas 5KFun Run, I for myself, my heirs, executors, and administrators, hereby release Mount Carmel Academy, its officers, employees, and agents, and all their sponsors from all claims for injury and damage to persons or property sustained by me or any third party arising out of, caused by, or resulting from my participation and hereby agree to indemnify and hold said parties harmless from such claims, and all expenses arising there from. I further warrant that I have trained for a walk/race of this distance and under these weather conditions, and that I am fit to enter. I also participate with knowledge and understanding of any recommendations made by my physician or medical service.
Participant’s Signature__________________________________________
Participant’s Printed Name_______________________________________
Parent/Guardian Signature_______________________________________
(For participant under 18)
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