May 4, 2014 (Sunday) Assembly Time: 4:30am Gun Start: 5:00am CINEMA Square Grounds

LAST NAME FIRST NAME M.I.

COMPLETE ADDRESS

/
AGE

MALE FEMALE
GENDER *STUDENT discount given upon presentation of OFFICIAL SCHOOL ID.

BIRTHDATE mm/dd/yyyy

SCHOOL / ORGANIZATION

IN CASE OF EMERGENCY, PLEASE CONTACT:

NAME

CONTACT NUMBER

CATEGORY

SINGLET SIZE

3K 6K
Rules & Regulations: WAIVER:

Extra Small Medium Small Large

REGISTRATION FORM No.

Participants below 18 years old must have their forms signed by a parent or guardian; No change of singlet size after submitting this form. Singlets are subject to availability; Race bib numbers should be pinned in front of the singlet and worn all times during the event; The organizers reserve the right to disqualify any participant based on certain circumstances; The organizers decisions are final. In consideration of my entry, I, my heirs, executor and administrators release and forever discharge the organizers, the local government, the servant agents and subcontractors and all volunteer community groups, and all organizations assisting this event (sponsors, producers, their agents and representatives) of all liabilities, claims, damages, or cost which I may have against them arising out of or in any way connected with my participation in this event. I understand this waiver includes claims based on negligence, action or inaction of the above parties. I fully recognize the difficulty of this event and declare that I am physically fit and able to compete in this event safely and have not been told otherwise by a medically qualified person. I agree that in the event of race cancellation due to storm, rain, inclement weather, wind or any other unforeseeable or act of God condit ions, my entry shall be non-refundable. I have carefully read this registration form and agree to abide by all rules and directions of all race officials on the day of the race.
________________________________________________ Signature over Printed Name / Date ________________________________________________ Parent/Guardians Signature over Printed Name / Date

May 4, 2014 (Sunday) Assembly Time: 4:30am Gun Start: 5:00am CINEMA Square Grounds SINGLET CLAIM STUB No. ____ NAME: ____________________
Distribution of Singlets starts on April 25, 2014 @ CINEMA PHARMACY.

SINGLET SIZE: _____________ BIB No: _____________

Amount PAID: _____________ http://www.facebook.com/molavecinemasquare