Fall Fling 5K

Make checks payable to: GFLRRC
Mail to: Fall Fling 5K, PO Box 2512, Ft. Lauderdale, FL 33303-2512
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_________________________________ Champion Chip Number ______________________________________________________________________ E-mail ___________________________________  ______________________   ________      (  ) (  ) Last Name                            First Name            Age on Race Day  Male Female ________________________________________________________________________ Mailing Street Address (Indicate Apt. No. and /or C/O) _________________________________   ______________________   _____________ City                                State                     Zip Code               ______   ______   ___________   _____________________________________ Birthdate     Month     Day      Year         Telephone Entry Fees                Pre-Reg      Race Day    Event GFLRRC Members              $20.00        $30.00     5K Run        (   ) Non-Members              $25.00        $30.00     5K Walk          (   ) 19 & Under                $10.00        $30.00     Kids Fun Run   (   ) Kids Fun Run & Youth Mile   $3.00         $5.00     Youth Mile          (   )                                                                                                                                             T-Shirt Size Small ( ) Medium ( ) Large ( ) X-Large ( )

In consideration of accepting this entry, I, the undersigned, intending to be legally bound hereby, for myself, my heirs, executors and administrator, waive and release any and all rights and claims for losses and damages I may have against the Greater Fort Lauderdale Road Runners Club, race directors, their officers, directors, members and volunteers, any and all sponsors including other parties and their representative successors, and assigns for any and all injuries suffered by me in said event. I attest that I am physically fit and have sufficiently trained for the competition of this athletic event and competition which I am voluntarily entering at my own risk. My physical condition has been verified by a licensed medical doctor. Further, I hereby grant full permission to any and all foregoing to use photographs, videotapes, motion pictures, recordings or any other record of this event for any purpose whatsoever. USE OF HEADPHONES, OR ROLLING SKATES / INLINE SKATES, BABY JOGGERS ARE NOT PERMITTED ON THE COURSE. NO ONE MAY ENTER THIS EVENT WITHOUT SIGNING THIS OFFICIAL WAIVER.

_____________________________________________ _________________________________________ Signature Date / Signature of Parent or Legal Guardian if Under Age 18 Date