Please Cut Off and Return to: Run for Ruth House 5K C/O Rebecca Randall Ruth House, 311 S. Central Avenue, Umatilla, Florida 32784
Make Checks Payable to: Ruth House
Name: _______________________________________________________ Grade: _____ Age: _____ M/F____
I do ____ do not ______ give permission for my photo/child if under 18 to be placed on the event website.
T-shirt Size ______ Small ________Medium _________Large ________XL (no guarantee of t shirt sizes after January 10; extras available for $10 on race day)
Address: (include zip) ____________________________________ Email Address: __________________________
Parent/Guardian: (if under 18 day of event)___________________________Phone: H ______________ W____________
Emergency Contact: _________________________________________________ Phone: ________________________
Insurance Company: _______________________________________________ Policy #: _________________________
Allergies or medical conditions:________________________________________________________________________
I understand that running/walking is a physical sport and injuries may occur. I release the organizers, staff of North Lake Park, sponsors, the employees or sub-contractors from Athletics Scoring Providers from any legal responsibilities for any possible injury or consequences that may occur. I also authorize the meet director/club sponsor of the event to act on my behalf if an injury occur and I cannot answer responsibly. I understand if my child under the age of 18 is participating, the same procedures apply to my child.
(Parent)Signature: _______________________________________________________ Date: _____________________
Date received: _________Payment Type: Check #__________ Cash: ________Received by: _________________
Transitional Shelter for Women and Children in Crisis