Online Registration
NAME
BAR NO.
FIRM
ADDRESS
CITY
STATE & ZIP
PHONE
BIRTH DATE
E-MAIL
RECRUITING ORGANIZATION
(must be filled in for team recruiters'
competition credit)
SPEED COMPETITION TEAM
(team name)
SHIRT SIZE
Select
Child XS
Child S
Child M
Child L
Adult S
Adult M
Adult L
Adult XL
Adult XXL
BABY SHIRT SIZE
(baby stroller participants only)
Select
12 months
18 months
24 months
Child XS
DIVISION SELECTION
(select only one division per registrant)
DIVISION
GENDER
14 & Under
Male
Female
15 - 17
Male
Female
18-24
Male
Female
25-29
Male
Female
30-34
Male
Female
35-39
Male
Female
40-44
Male
Female
45-49
Male
Female
50-54
Male
Female
55-59
Male
Female
60-64
Male
Female
65-69
Male
Female
70-74
Male
Female
75 & Over
Male
Female
Wheelchair
Male
Female
Baby Stroller
Male
Female
Chaise Lounge
In Absentia
PAYMENT
PRE-REGISTRATION
(before 5/2/12 after $35.00)
$25.00
BABY STROLLER
(add to regular registration fee)
$10.00 in addition to regular registration
CHARITABLE DONATION TO
"AND JUSTICE FOR ALL"
$
TOTAL PAYMENT
$
PAYMENT METHOD
American Express
Visa
MasterCard
NAME ON CARD
CARD NO.
Personal
Corporate
EXP.
BILLING ADDRESS
ZIP
RACE WAIVER AND RELEASE
I waive and release from all liability of the sponsors and organizers of the Run/Walk, the USATF and USATF-Utah, and all volunteers and support people associated with the Run/Walk for any injury, accident, illness, or mishap that may result from participation in the Run/Walk. I attest that I am sufficiently trained for my level of participation. I also give my permission for the free use of my name and picutres in broadcasts, newspapers, and event publications. I consent to the charging of my credit card submitted with this entry for the charges slelected. I understand that the entry fees are not refundable.
