Please enable JavaScript in your browser to complete this form.Name of Participant *FirstLastAge *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Comment or Message (Allergies, Health Conditions, etc.) *Fun Run Child EntryPrice: $10.00Payment (Credit Card) *CardName on CardRelease of Liability *I AgreeRelease of Liability: I wave and release all claims that might have been brought against DPSIC and agents, for any and all injuries or losses, which may be suffered because of my participation or my child’s participation in the above activity, in consideration of permission of DPSIC to participate in the activity. I consent to my child’s participation in this activity and authorize the organization to provide emergency medical treatment for my child on my behalf. To the best of my knowledge, my child has no physical or other conditions, which would interfere with his/her participation.Signature *Clear SignatureSubmit