|
|
Cure Sickle Cell 5K Walk Registration
|
|
|
|
First Name |
|
|
Last Name |
|
|
Title |
|
|
Gender |
|
|
Address Line 1
|
|
|
Address Line 2
|
|
|
City |
|
|
State |
|
|
Zip |
|
|
Phone Number |
|
|
Email Address |
|
Name of Organization
(if walking as a group) |
|
|
T-Shirt Size |
|
|
|
I hereby certify I am adequately fit to walk in this activity. In consideration for the acceptance of this entry, I, the undersigned, for myself, my personal representative, beneficiaries, and heirs, knowingly waive, release, and discharge all rights and claims which I have or may have hereafter accrue to me or my estate against the Cure Sickle Cell Foundation, Inc, Jackson State University and/or any other sponsors, organizers and volunteers and assigns for any and all injuries or death suffered by me in this event. I will also allow my picture to be used in publication as a result of this race.
|
|
|
|
|
|
|
|