Name:
Address:
Address:
City:
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In consideration of the foregoing, I, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for any claims damages I may have against any of the sponsors, volunteers, organizers, City of Shelbyville, The Intelliplex Park,  Energy2Action, LLC, and The Shelby Roadrunners,  for any and all claims of damages, demands or loss actions whatsoever which may arise as a result of my participation in this event.  I understand and acknowledge that participating in this run/walk  event may expose me to dangers from both known and anticipated risks.  I understand that the course is not closed to traffic and that I could be at risk from traffic, other runners and cyclists, bad weather, ice and rough terrain along the course.  I acknowledge that some sections of this run  course may be off road or rough road and may contain areas where I will  be at risk of tripping and falling.  I attest and verify that I am physically fit and have sufficiently trained for the completion of this event and my physical condition has been verified by a licensed medical doctor.  I understand that this event may be canceled or delayed for any legitimate purpose or reason and that my entry fee will not be refunded under those circumstances or for any other reason.   Further, I grant full permission to any and all of the foregoing to use my likeness for any legitimate purpose whatsoever.





Age on Race Day:
All credit card payments are received on line through Pay Pal, a reputable and secure payment center. No entity or individual is given access to your credit card  information other than Pay Pal  - not even Energy2Action.  Please note that you will be charged $1 for processing through PayPal.  
Are you registering yourself or someone else?
If you are registering someone else, what is YOUR name?




NEW YEARS DAY 
FAST BLAST
5K RUN/WALK
January 1, 2018
10:00 A.M.
City Hall
44 W. Washington Street
Shelbyville, IN  46716

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