MIKE JENSEN MEMORIAL
SATURDAY APRIL 7th, 2012
FUN RUN & WALK
5K run/walk, you decide……………
Run/walk begins at 10:00 a.m.; late registration begins at 9:00
Lewiston Kiwanis park on the levy
Cost: $20 Pre-registration comes with cinch sack back pack…….
$10 Pre-registration without Cinch sack
Pre-registration ends March 31st
$25 late registration with cinch sack, $12 without cinch sack
All proceeds will benefit The Willow Center for Grieving Children
Registration Form (Please Print)
Name: _______________________________ Age: ______ Gender: M or F
Address: _____________________________ City: ___________ St: _____ Zip: _____
Email: _______________________________ Phone: __________________
Please Read the following statement and sign before submitting entry.
I know competing in a fun run is a potentially hazardous activity. I should not enter and compete unless I am medically able and properly trained. I assume all risks associated with competing in this event, including, but not limited to falls, contact with other participants, the effects of weather, traffic, interactions with non-participants and the conditions of the road all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of the acceptance of my entry, I, myself and anyone entitled to act on my behalf, waive and release any and all sponsors and organizers, their officers, agents and assigns, the race director and volunteers from all claims or liabilities of any kind arising out of my participation in this even though that liability my arise out of the negligence or carelessness on the part of the persons named in this waiver. I also understand that my entry fee is non-refundable and non-transferable. A parent must sign if the child is under 18 years of age. This certifies that the child has permission to participate and agrees to the previously stated waiver.
Signature: ___________________________________ Date: _____________
Parent/Guardian (if under 18 years of age):_______________________ Date: ________
Please mail registration to Michelle Hill, attention Mike Jensen run.
1906 birch drive, Lewiston Id 83501