Registration

Unity Gardens Run Toward Unity 5k Run / Walk Registration Form

Date Sept 22^nd 2012
Time : Race Starts at 9am
Race Day Registration Starts at 8am

Please copy form
Send Entry Form with Check Payable to:

Unity Gardens 5k

PO Box 10022

South Bend IN. 46680

Name:____________________________________________ Gender: M / F

Age on Sept 22nd 2012 _______

Address:______________________________City:______________ State:_____Zip: _______

Phone Number ___________________________e-mail ________________________________

Event:  5K Run□ 5K Walk

Cost $ 20  Includes T-Shirt

Day of Race $ 20 Cannot Guarantee-Shirt for race day entries

T-Shirt Size: □ S□ M□ L□ XL □ XXL □ Youth S □ Youth M□ Youth L

Additional Donation Amount _________Total enclosed _________

Release form: I know that running a road race is a potentially hazardous activity. I should not enter and participate unless I am medically able and properly trained.I understand that traffic will be controlled but I am ultimately responsible for my own safety.Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Unity Gardens Inc.Employees and it's, volunteers, all city, county, and state governments, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event.

____________________________________________________________________________________________________

SignatureDateParent’s Signature if entrant is under 18 yrs.

(this form may be duplicated)

Unity Gardens Contact Info
growunitygardens@yahoo.com
574-315-4361