Name:

Address:

City/State/Zip:

Phone #

Age on day of walk:

Email:

Today's Date:

Circle One: MaleFemale

T-Shirt Size: SMLXLXXLXXXL

Other Size:

WAIVER - Must be signed by all entrants!
I, for myself and anyone entitled to act on my behalf, waive and release The Children's Home.,Inc all sponsors, their representatives and successors from all claims or liabilities of any kind arising out my participation in the 2016 Community 5K Walk. I further grant permission to the Children's Homes, Inc. and/or agents authorized by them to use any photographs, videotapes, motion pictures, recording, or any other record of this event for any purpose.

Signature of Participant:

Date: