May 7, 2017 (Sunday) Assembly Time: 4:30am Gun Start: 5:00am

LAST NAME FIRST NAME M.I.

COMPLETE ADDRESS

/ / MALE FEMALE
BIRTHDATE mm/dd/yyyy AGE GENDER CELLPHONE NUMBER

SCHOOL / ORGANIZATION *STUDENT discount given upon presentation of OFFICIAL SCHOOL ID.
IN CASE OF EMERGENCY, PLEASE CONTACT:

NAME CONTACT NUMBER

CATEGORY T-SHIRT SIZE REGISTRATION

3K 6K
FORM No.

Rules & Regulations:

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.

WAIVER:
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 conditions, 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 7, 2017 (Sunday) Assembly Time: 4:30am Gun Start: 5:00am CINEMA Square Grounds
TSHIRT CLAIM STUB No.

NAME: ______________________________________

TSHIRT SIZE: _____________ BIB No: _____________ Amount PAID: _____________

Distribution of Singlets starts on April 20, 2017

at the FUN RUN BOOTH near CINEMA PHARMACY.
http://www.facebook.com/molavecinemasquare