2019 Micah Mandate RUN FOR LIFE

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Team name   First name   Last name   Email address   Date of birth    MM 01 02 03 04 05 06 07 08 09 10 11 12    DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    YYYY 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920    Gender -- Male Female   Phone #   Address   Emergency contact name   Emergency phone #   Distance Choose one 5K Run 5K Walk   Category Choose one 0-9 10-12 13-15 16-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 and up Choose one 0-9 10-12 13-19 20-29 30-39 40-49 50-59 60-69 70 & Up   Event entry fee TBD

T-shirt size  * None Youth Small Youth Medium Youth Large Small Medium Large Extra large XXL   Additional Donation  * NoYes   USD

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Please review the waiver provided by the event organizer and click the check box below to accept it. Print waiver Micah Mandate Run for Life Disclaimer Form WAIVER: In consideration of my entry and being allowed to participate in this event, I hereby for myself, my heirs, executor and assigns, waive and release any individuals or organizations who assist or support these events from any liability for illness, injuries, or property damage I may suffer as a result of my preparation for or participation in this event. I intend this waiver to include claims of negligence. I hereby understand and agree to assume all risks associated with my participation in this race. I further agree to indemnify and any organizer, participant or other related party for any and all liability for property damage or bodily injury caused as a result of my participation in this race. I certify that I am physically fit to participate in this race. I accept the terms of the waiver Name of parent or guardian who approves this activity