Check One:  ___ under 17     ___ 18-39     ___ 40-49     ___ 50-59     ___ 60+

Last Name _____________________     First Name ______________________

Mailing Address __________________________________________________

City ______________________________      State ____      Zip Code ________

Date of Birth ____ - ____ - ____    Sex (circle)  M  F      Age Day of Race ______

Home Phone ___________________    Work Phone ______________________

Running Club or School _____________________________________________

WAIVER: Please enter me in the Jeremiah's 5K. I agree to assume all responsibility for all risk of damages or injury to me as a participant in this event. In consideration of being accepted as an entrant in the Jeremiah's 5K, I hereby, for myself, my heirs, executors and administrators, release and discharge and and all individuals and organizations associated with the race from all claims, damages, rights to action, present or future, whether the same be known, anticipated, or unanticipated, resulting from or arising out of, or in incident to my participation in this event. I hereby certify that I will not participate in the Jeremiah's 5K unless I am physically fit and sufficiently trained for competition in the race. I also grant permission for the use of my name and/or picture in any broadcast, photograph or other account of this race. I understand that bicycles, skateboards, baby joggers, roller skates or blades, animals and radio headsets are not allowed in the race and I will abide by this guideline.