Registration Form -  I LOVE "MOTHER'S" DAY 5K & FUN RUN
Circle the appropriate race.
♣    5K($20 Before April 12th -afterwards $25           ♣ 1/2 MILE $5 anytime     
♣    

    

                                                                                                         
                                                                                                                                                                                                                                                                          
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NAME      (First & Last)                                                                                                                              
 
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ADDRESS                                                                                                                                                       PHONE
                                                                    
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CITY                                                                                                    STATE                 ZIP                           AGE                          GENDER
                                                                                                           
In consideration of this entry, I, for myself, my heirs, devises, executors, administrators and assigns hereby waive, release and discharge any and all Claims against Premier Racing Institute, American Running Company, Pinellas Race Place Magazine, Clearwater Police Dept, City of Clearwater; Pinellas County Sheriff's Dept., American Running Company sponsors conducting this event, or their employees, representatives, or successors, for any and all damages or Injuries I may suffer. I hereby grant permission for the free use of my name and picture in any broadcast, brochure or account of this event. INSURANCE DOES NOT COVER THESE ACTIVITIES: BIKES, SKATEBOARDS, ROLLERBLADES, MULTI-SPORT EVENTS, ANIMALS, RADIO HEADSETS.
 
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SIGNATURE (Parent signature if under 18)                            Date
MAKE CHECKS PAYABLE and Mail To:                            Premier Racing Institute
                                                                                26024 US Highway 19 North, Cleawater, FL33763