For complete details, visit www.wiruralhealth.org, or register online at www.ACTIVE.com ... Name. FIRST. MIDDLE. LAST. E
2016/6/30
1st Annual Rural Health Initiative
Choose to Move 5K Run/Walk Sunday, August 28, 2016 Waupaca County Fair 602 E. South Street ▪ Weyauwega, WI 54983 ___________________________________________________________________________________
REGISTRATION FORM Each participant must complete a Registration Form. For complete details, visit www.wiruralhealth.org, or register online at www.ACTIVE.com
(If registering via mail, payment MUST be sent to RHI at 100 County Road B, W200, Shawano, WI 54166) ____________________________________________________________________________________
Complete the form below. Full Name FIRST
Address Phone Number
(
LAST
MIDDLE
LAST
)
Emergency Contact Name
FIRST
Emergency Contact ( Phone Number
Age T-shirt Size (circle one)
MIDDLE
)
Gender (circle one) Small Medium
Male Large
Female X- Large
XX-Large
Consent (REQUIRED for each participant): The undersigned entrant acknowledges and confirms that I am aware of the inherent risks of participating in the event due to physical exertion, health problems, contact with other participants, objects on the course and on the farm, and other unforeseen events. In consideration of accepting this entry, I, the undersigned, intending to be legally bound, do hereby agree not to sue, and do hereby waive and release the Rural Health Initiative, Waupaca County, Waupaca County Fair, Waupaca County Fairgrounds, all sponsors, organizers, officials, volunteers, their employees, representatives, successors, and assigns from any and all claims, damages, injuries, or actions suffered by me (or my minor child) or arising out of my participation in said event. I, hereby, consent to the use of my voice or picture or any other record of this event for any purpose whatsoever. This release applies to, inures to the benefit of, and binds all parties hereto, their heirs, representatives, successors, and assigns. This entry is invalid unless signed by the entrant. If entrant is under eighteen (18) years of age, parent or legal guardian must sign entry. The official race director reserves the right to reject any entry.
Print Full Name FIRST
Signature
MIDDLE
Date
LAST
