Last Name

First Name

Street Address

City

State

Zip Code

Country

Phone Number --

Email Address

Age

Sex

My T-Shirt size

xs s m l xlxxl

Fees:

5k Run $____________ ($15.00 - prices raise to $20 after 7/21)

2 Mile Walk $__________ ($15.00 - prices raise to $20 after 7/21)

Youth Run $___________($5.00 - prices raise to $6 after 7/21)

Family $____________ ($45.00 for 2 adults and minors under 18 in the same family please)

Additional Chicken Barbeques

@ $6.00 x _____ $___________

Total Enclosed $__________________

Make Checks or money orders payable to:

billy mead 5k ALS Run for Research

No cash and no refunds.

Please sign and date this form only after you have read the waiver.

***Waiver***I know that running or walking in a road race is a potentially hazardous activity. I should not enter the run/walk unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the race. I assume all the risks associated with running/walking in this event including, but not limited to: falls, contact with other participants, the effect of weather (including high heat or humidity), traffic and conditions of the road, all such risks being know and appreciated by me. Having read this waiver and knowing these facts, I, for myself and anyone else entitle to act on my behalf, waive and release the billy mead ALS run for research and the City of Dunkirk and all sponsors, their representatives and successors from all claims of liabilities of any kind arising out of m participation in this event even though the liability may arise out of negligence or carelessness on the part of the persons named in the waiver.

Signature Date

Parent's Signature if under 18 years:

Print Name

Please print this form and mail to:

billy mead 5k Run for Research

PO Box 466

Dunkirk, NY 14048

Thank you!