Registration Form – Gonzales Rx Pharmacy's Orange & Black 5K

Name *

First

Last

Mailing Address *

City *

State *

Zip *

Phone

Email *

Age *

T-Shirt Size *

Division *

Registration *

Payment Option *

I hereby certify the following: I am physically fit and have received clearance to participate in the 5K run/ walk on Thursday July 4th, 2024. Therefore, I hereby waive, my heirs and assigns, and my estates. I discharge the sponsors, organizers, affiliates, as well as their agents and employees, from all claims that may occur as a result in my participation in the 5K. *

(Participant signature) (Date) (If under 18, Guardian’s signature) (Date) (Student’s Name)