1st Annual MAMMO OR BUST Fun Run in Custer, SD – October 15th, 2016 – Registration Form

mamoorbustfunrun

Registration Form

Mammo or Bust
5k Run/Walk and 1 Mile walk
Saturday October 15 2016
Please fill out form and return to the CRH Imaging Department.  You may also register the day of the race at 8 am at the Custer Regional Medical Clinic parking lot. Race will begin at 9 am. The fee for all races will be $10.00. Checks may be filled out to Mammo or Bust.  Prizes will be awarded to the top finishers and we will also have T-shirts for sale as well. Thank you.

Name:________________________________  Age:____  DOB:____________

Address:_____________________________________________________

City:______________________________ State:__________ Zip:___________

Email: _______________________________ Phone:_____________________

Please circle the race you will be participating in below:

5k run                                            5k walk                                  1 mile walk

 Waiver: I know that running/walking a road race is a potentially hazardous activity and that I should not enter unless I am medically able and properly trained. I agree to abide by any race official relative to my ability to safely complete the run. I assume all risks associated with running this event including but not limited to: falls, contact with other participants, the effect of the weather, traffic, the conditions of the course, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and inconsideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Mammo or Bust fun run and all event sponsors from all claims or liabilities of any kind arising out of my participation in this event.

 

Signature (if 18 or older) ____________________________________Date __/__/___

Parent or Guardian Signature (if under 18) _____________________________________

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