Race information ……………………………………………………………..

Date: Saturday, February 5th, 2011

Time: 7:30 am- 9:30 am

Location: Inside Wickham Park

2500 Parkway Dr, Melbourne, FL, 32935-2335

Registration/ Amenities …………………………………………………

Cost: flat fee of $15 on race day

Amenities: t-shirt for all runners and breakfast food and

refreshments at the end of the race.

Participants name: ______________________ Age: ______________ Gender: M F

Shirt Size: S M L XL Phone number: (___) __ __ __ __ __ __ __ Email: _______________

For more info contact Kristy McCoy @ (321)514-5865 or email at richmccoy@bellsouth.net

I, the undersigned, in consideration of acceptance of the entry and registration as participant of the 5k Family Fun Run hold
harmless and waive any and all claims which I and my heirs or assigns may now or hereafter have against the sponsors of 5k
Family Fun Run, and all of the officials which may indirectly or directly result from my participation in this event. I further
warrant and represent that I am in proper physical condition to participate in this event and am not participating in this event
against physician’s advice nor am I taking medication which would impair my health or ability to participate in this event.

Signature of Parent or Guardian: _________________________________________________________

(if participate is under the age of 18)

Signature of Participant: __________________________________________________________________