2011 JACKRABBIT STAMPEDE ENTRY
Stampede Information Page




NAME:  Last______________________ First_____________________ Middle__________

ADDRESS: Street_________________________ City___________________ State____ Zip________

HOME PHONE: (____) - ___________________ WORK PHONE: (____) - _______________

Date of birth:_______________________ AGE:____ Female:_____ Male:_____


ADULT T-THIRT SIZE:       __ Medium    __ Large    __ Xlarge    __ XXlarge    __ XXXlarge

YOUTH T-THIRT SIZE:       __ Medium    __ 


ENTRY FEE ENCLOSED:
Postmarked on or before August 31, 2011 $15.00
Late: after August 31, 2011 $20.00

HOW DID YOU OBTAIN THIS FORM?
__ requested by mail
__ unsolicited mail
__ by FAX
__ via the internet
__ other:_____________________ 		                              

Make checks payable to:
Forney Lions Club
and mail to:

Forney Lions Club
P.O. Box 1332, Forney TX 75126
Jackrabbit5k@hotmail.com
Form may be photocopied for
additional applications

NO REFUNDS






WAIVER OF CLAIM BELOW MUST BE SIGNED

















WAIVER OF CLAIM

Please read carefully, must be signed.



In consideration of the acceptance of this
registration entry, I the undersigned assume
full responsibility for any injury or accident
which may occur during my participation in
the event or while I am on the premises of the
event. I hereby release and hold harmless
Forney Lions Club , City of Forney, the sponsors,
the promoters, and all other persons and
entities associated with the event, or their
agents, employers, or otherwise. I will not
enter and participate unless medically able
and properly trained. I also know that
although police protection will be provided,
there may be traffic on the course route. I
assume the risk associated with this event,
including but not limited to, falls, contact with
other participants, the effects of weather, and
the conditions of the road. Fees are nonrefundable.
T-shirt size is not guaranteed. I
have read the foregoing and certify my agreement
by this signature, and my parent's or
guardian's signature if under 18 years of age.


I HAVE READ AND UNDERSTOOD ALL OF THE ABOVE.

Signature:_______________________________________________________________

Date:____________________________________________________________________

Signature of Parent:_____________________________________________________
(If participant is under 18 years of age on the day of the event.)



In case of accident call:_________________________________________________


Phone # (___)_____________________________________________________________