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* 1. Personal Information:

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* 2. Race:

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* 3. In case of emergency please contact:

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* 4. Age:

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* 5. Gender:

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* 6. Pre-registration will be from March 1, 2019-June 1, 2019.  Cost of pre-registration is $25 - payable day of the event; Registration fee after June 1st or day of race will be $30.00, also payable day of the event.  You will not be guaranteed a hat and can koozie if you do not pre-register.

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* 7. In consideration of my entry, I release and forever discharge the organizers, volunteers, and representatives assisting in the event from all liabilities, claims, damages, or costs; which I may have against them arising out of, or in connection with my participation in this event.  I understand that this waiver includes claims due to the negligence, action or inaction of any of the above parties.  I full recognize that possible consequences of my participation in this event and declare that I am physically fit and able to compete safely and not told otherwise by a medically qualified person.  I have carefully read and understood this entry form and agree to abide by all rules and directives of all race officials before, during, and after the race.  

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* 8. Date:

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