registration form&waiver .pdf

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MUSTACHE DASH 5K & FUN RUN/WALK
Benefiting Sherry Beth Clark, pancreatic cancer patient
January 14, 2017 at 9am

The Start/Finish line will be at the Langdale Farmers Market Shed and run on the Rails to
Trails. There will be a 5K and a 1 Mile Fun Run. Registration will include a Mustache Dash
event shirt.* This is a rain or shine event and refunds will not be issued. Please fill out a
separate form for each individual participant.

First Name: _ _______________________________________________ Last:______________________________________________________
E-mail Address:__________________________________________________________________________________________________________
Address:_____________________________________________________________________________________________________________________
City/State/Zip:___________________________________________________________________________________________________________
Cell:____________________________________________________________________________________________________________________________
Gender:

Male

Female

Birthdate: ____________/____________/____________ Age: ______________

Shirt Size:

Youth:

Small

Med

Large



Adult:

Small

Med

Large

Early Bird 5K @ $30: ____________

XL

XXL

Early Bird Fun Run/Walk @ $25: ____________

Must be postmarked by November 18, 2016

Basic 5K @ $35: ____________

Basic Fun Run/Walk @ $30: ____________

Must be postmarked by December 16, 2016, after which registration must be done online.

Additional Shirt: #______________ @ $20 each= _________________ Size:_________________________________________
#TeamSherry Bracelets: #________ @ $5 each=___________ Total Enclosed:__________________________
Forms can be dropped off at All Star Computers or mailed to:
Mustache Dash, Attn: Amy Nolen, 1175 Plantation Road, Valley, AL 36854
Checks or money orders payable to Amy Nolen.
*Sizes only guaranteed if you register by Dec. 16, 2016

SIGN WAIVER ON REVERSE SIDE

DASH
Mustache Dash 5K & Fun Run/Walk, Waiver & Release Form
I,__________________________________________________________________(print name), acknowledge that my participation
in the Mustache Dash 5k & Fun Run/Walk involves a risk of injury, including bodily injury, and
assume the risk for same. On my own behalf and on behalf of my heirs and legal representatives and to the fullest extent permitted by law, I hereby release and discharge the Mustache Dash, The City of Valley and their respective organizers, officers, employees, affiliates,
members, agents and representatives, of and from any and all liability for injury, death, or
damages and/or any other claims, demands, losses or damages, incurred by me in connection with any aspect of the Mustache Dash.
Signature:_____________________________________________________________________________________________________ Date:________________________
Signature of Parent:_____________________________________________________________________________________ Date:________________________
If under 18

Scan me to register online!


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