First Name Last Name
List names and ages of additional runners (family registration)
Family Name (family registrations)
Team Name (business, church, or other group)
Participating in the: 5k 1k
Address City
State Zip
Email
Phone Select Phone # Provided
Age on Race Day Male Female
Cotton Pickin' Release/Waiver: In return for your accepting my entry, I, for myself, my heirs and my personal representatives, waive and release any and all rights and claims I have, now and in the future, against Fayette Cares, sponsors, and all of their officers, employees, representatives, volunteers, successors and assigns, for any and all injuries, illnesses, losses, damages or death in any way connected with my entry, traveling to and from or participation including but not limited to falls, contact with other participants or vehicles, effect of the weather and course hazards. I am aware that participation is strenuous and may be hazardous. I am physically fit and sufficiently trained to complete the event, and I agree to abide by all rules and by any decision of a race official relative to my ability to safely complete the race. I authorize race officials to have me transported to a medical facility if in their discretion I appear ill or injured, and take full financial responsibility for this action. I authorize all above-named parties to use any photo, video or other record of this event, and any information contained in my application, for any purpose whatsoever, without any consideration due to me. I have read and fully understand this entire application.
I agree to the above race waiver and disclaimer.
Initials of athlete over 18 years of age or parent/legal guardian of minor under 18 years of age or legal guardian of incapacitated and/or mentally challenged person.
