colorful 5 k by the bay form
TRANSCRIPT
“Serving our Youth” Boys & Girls Club of Palacios 2014
15th Annual Cinco de Mayo Celebration / Fundraiser
Registration Form
Name: ___________________________________
Address: ___________________________________
City: ____________________ State: ______ Zip: ________
Phone # : ___________________
Email Address:________________________________________
Sex: ___ Male ____Female Age as of 5-3-14 _____________
Emergency Contact Name: _____________________________
T-shirt size
Phone # :_________________________________
Please check box below
T-shirt and bag of color included in registration
TEAM NAME: _______________________________________________ Go to www.palacioskids.org to register online or for information about the Colorful 5K by the Bay and packet pick up locations.
Entry form: Please print and mail to: Boys & Girls Club of Palacios, PO Box 843, Palacios, TX 77465 Make checks payable to: Boys & Girls Club of Palacios For more information, contact the Boys & Girls Club @ (361) 972-2642 or email [email protected] This waiver of claim statement must be signed and submitted with registration in consideration of acceptance of this entry. I waive and release any and all claims I may have against the Boys & Girls Club of Palacios or its volunteers or firm or organization for any and all injury, illness, or loss which may directly or indirectly result from my participation in this event. This waiver shall be binding on my heirs, legatees, administrators and assignees. This entry is invalid unless signed by entrant. If entrant is less than 18 years of age, a parent or guardian must sign this form.
______________________________________________ ______________________________________ Entrant’s/Parent’s signature Date Print Parent Name if entrant is under 18
Solo Runner/Walker
□ $30 February
□ $35 March
□ $40 April
□ $45 May
Adult - 18 or older when part of a team of 4 or more
□ $25 per person February
□ $30 per person March
□ $35 per person April
□ $40 per person May
___ YS
___ YM
___ YLG
___ AS
___ AM
___ ALG
___ AXL
___ 2XL
___ 3XL
___ 4XL
******* 4 Blast Zones *******
Ages 5 and under FREE
Youth – Under 18 when part of a team of 4 or more
□ $20 per person February
□ $25 per person March
□ $30 per person April
□ $35 per person May
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