Family Fun Run Entry Form – Dash Point Social & Improvement Club

Name of First Adult Participant (Signer) *

First

Last

Name of Second Adult Participant

First

Last

First Card) (Signer)

Child 1 *

First

Last

Age *

Child 2

First

Last

Age

Child 3

First

Last

Age

Child 4

First

Last

Age

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Comment or Message (Allergies, Health Conditions, etc.) *

Fun Run Family Entry

Price: $20.00

Payment (Credit Card) *

Card

Name on Card

Release of Liability *

I Agree

I waive & release all claims that might have been brought against DPSIC & agents, for any & all injuries or losses, which may be suffered because of my or my family/ children’s participation in the above activity, in consideration of permission of DPSIC to participate in the activity. I consent to my & my family/children’s participation in this activity & authorize the organization to provide emergency medical treatment for myself & my family/children on my behalf. To the best of my knowledge, I & my family/children have no physical or other conditions, which would interfere with my or their participation.

Signature *

Clear Signature