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Domestic Violence Walk/5kRun
Registration Form
Saturday, October 23, 2010
Idlewild Park, Easton, Maryland
Registration begins at 8:00 am...Walk/Run starts at 9:00 am
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5K Walk Participant
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Competitive 5K Run Participant
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Last Name:
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First Name:
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Age on Walk/Race Day:
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Male
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Gender:
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Female
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Email Address:
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Street Address:
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State:
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Zip:
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City:
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Phone Number:
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XXL
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XL
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T-shirt Size:
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S
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M
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L
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How did you hear
about the Event?:
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TEAMS (A team consists of 5 or more walk or race participants)
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I will be a:
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Team Captain
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Member of Team
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Team Name:
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Team Captain Name:
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Please contact me, I would like to:
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Include my company as a sponsor
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Serve as Volunteer
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Waiver: In submitting this entry, I am intending to be legally bound. On behalf of myself, my heirs, executors
and administrators, I hereby waive, release and forever discharge any and all rights and claims which may
hereafter occur to me against Witney’s Lights, Inc., all sponsors, directors and volunteers from any and all
claims, injury or actions sustained or suffered in connection with my participation in the event. I hereby grant
full permission to all of the above to use my name, likeness and photographs for any publicity and promotional
purposes without obligation or liability to me. I understand that the streets along the course will reopen at the
discretion of the City of Dover Police Dept. and will abide by their direction.
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