“THINK PINK”

Breast Cancer Awareness 5K

April 17, 2010 - 9 a.m.

(Old High School, #1 Tiger Drive - Republic, MO)

(Email this form completed to gmansker@caroljones.com or mail this form to 3883 S. Deerwoods Ln. Republic, Mo 65738.)

· Register deadline is Saturday April 10.

· If more than one entry you can make copies.

· Cost is $20.00 (includes a t-shirt)

· Make checks out to BCFO or Breast Cancer Foundation of the Ozarks

Last Name: ______________________________________First Name : ______________________________

Address: _________________________________City: ________________________State: ______________

Date of Birth: ________________Phone Number: ____________________ Gender F( ) M( )

Age as of April 17: __________ e-mail: ______________________________________________________

Shirt Size: S M L XL XXL

Race Wavier:

I know that running a road/trail race is a potentially hazardous activity, which could cause injury or death. I should not enter and run unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to any aspect of my participation in this event, including the right of the official to deny or suspend my participation for any reason whatsoever. I assume all risks associated with running in this event, including, but not limited to, falls, contacts with other participants, the effects of the weather, including high heat and/or humidity, conditions of the trails/roads, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act in my behalf, waive and release the Breast Cancer Foundation of the Ozarks, Lindsay Mansker and all volunteers, their representatives, any other staff involved in the Breast Cancer fun run 5K race, and their successors from all claims or liabilities of any kind arising out of my participation in the race even though the liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this for any legitimate purpose. I understand that if the race cannot be held on April 17 due to circumstances beyond the control of the race committee and sponsors, including, but not limited to, unsafe weather conditions or governmental ban, the race will be cancelled and will not be rescheduled for another date this year. Since the majority of event costs (entry forms, advertising, etc.) occur prior to the race, my entry fee will not be refunded. However, t-shirt orders will be honored. (T-shirt must be picked up by race day.)

Signature: ______________________________________________________________

(Parent signature if under age 18)