5th Annual WSO Power of Pink 5k Walk/Run

Registration Form

Entry Fee: $25.00 (Children under 12 no charge) – entry fees are non-refundable

(Free T-shirt included while supplies last pick up at friends N Co. or walk day while supplies last, limited children’s shirt’s available for $5.00)

Entry Fee is a donation to be donated to the Alamo Breast Cancer Foundation.

Payment: Cash or Checks payable to Women’s Service Organization or mail to:

1838 CR 119, Floresville, TX 78114

This is NOT a certified course.

Race Info: March 6, 2010 at 9AM. Hike/bike trail in Floresville.

Race will start at the metal depot at C Street and 1^st Street.

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Name: ________________________________________________________________

Address:_______________________________________________________________

Day Phone: ________________                                Home Phone: __________________

Email Address:____________________________________

___ Male ____ Female                                                     

T-Shirt Size: _________ (S/M/L/XL) (Free shirts while supplies last)

Are you a breast cancer survivor? ________(Yes/No)

WAIVER AND FITNESS STATEMENT FOR WSO POWER OF PINK 5K

I recognize and accept that participation in a marathon running or walking event is potentially hazardous activity. I assume all risks associated with the participation in this event. In consideration for my entry being accepted, I hereby waive release and discharge myself, my heirs, executors, administrators, legal representatives, assigns and successors in interest from any and all rights and claims which may hereafter accrue to me against the City of Floresville, Texas, and the sponsors of this event from all claims or liabilities of any kind arising out of my entry and participation in this event. I attest that I am physically fit and sufficiently trained for this event. I do also hereby consent and grant full permission to use my name, photograph or similar information for any publicity and/or promotional purposes without obligation, compensation and liability.

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Participant’s Signature (Parent or guardian’s signature if under age 18)                                            DATE