REGISTRATION FORM WESTERN HEALTH ADVANTAGE’S 21st annual 5K/10K Run & 5K Fun Run/Walk presented by KCRA 3 / KQCA 58 benefiting Sacramento Food Bank & Family Services Donation Registration ___ Timed Adult $40 ___ Timed Child* $25 ___ Untimed Adult $35 ___ Untimed Child* $30 ___Virtual Runner $35 *Child is age 15 and under Gender: M F Circle one Please accept my additional donation** of $___________________ THANKSGIVING DAY November 27, 2014 10K 8:15 a.m. | 5K 9 a.m. Helpful tips: Postmark by November 12, 2014 Only 7,000 timed registrations available Only early bird and regular registrants (by November 21) are guaranteed a shirt Make check payable to SFBFS Only one person per entry form Complete and sign waiver on each entry form Use credit card billing address below OFFICE USE ONLY Bib Number: Payment Type: Mail this form and payment to: Run to Feed the Hungry c/o SFBFS 3333 Third Avenue Sacramento, CA 95817 (Tax ID #94-3315566) **e-mail required for donation receipt Age: _____ Shirt Size ADULT: S M L XL XXL XXXL YOUTH S M L Circle one First Name: ________________________________________ Last Name: _____________________________________________________________________ Address: ___________________________________________________________________________________________________________________________ Contact e-mail***: __________________________________________________________________________ Phone***: __________________________________ Waiver and Signature: In consideration of your accepting my entry, I, intending to be legally bound, do hereby for myself and my heirs, executors, administrators waive and release any and all rights and claims for damages I may accrue against the persons and organizations affiliated with the race including but not limited to Sacramento Food bank & Family Services, City of Sacramento, Sacramento State, Scottish Rite Temple, Capital Road Race Management, all sponsors, volunteers, staff, subcontractors, agents, attorneys ad representatives for any and all injuries that may suffer while participating in the event or en route to and from the event. I consent to the use of my image in photos, videos and audio recording and film, of my participation in the event. I attest that I am physically fit and sufficiently trained for this competition, my physical condition verified by a licensed M.D. during the last 6 months. As part of the waiver, I acknowledge that I have read and understand all of the above. Signature****: ______________________________________________________________________________ Date: ____________________________________ Payment: __ VISA ___ MC __ AMEX Card Number: ___________________________________________________________ CVV: _______ Exp: ___________ Name on Card: ______________________________________________________________________________________________________________________ Signature: __________________________________________________________________________________________________________________________ *** Required ****All entrants must sign waiver, unsigned entries cannot be accepted (parent/guardian if under 18). All entrants must have separate entry form, copies attached.
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