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First Name:            Last Name:   

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Sex:    ? Female Male     Age: (day of race)       Shirt:    Size Small Medium Large Extra Large

Waiver:   In submitting this entry, I, intending to be legally bound for myself, my heirs, executors, and administrators waive, release and forever discharge any and all rights and claims for damages I have or may have against the organizers of this event, its principals, its employees, its volunteers, all sponsors and their representatives for any and all claims and damages, demands actions whatsoever in any manner, as a result of my participation in the Filthy Farm 5k, including travel to and from the event. I hereby consent to medical treatment in the event of injury, accident and/or illness during the event. I hereby grant full permission to any and all of the foregoing to use my name and likeness in any broadcast, telecast, video or print media reporting or advertising of the event without compensation. If you are under 18, a parent or legal guardian must sign this form.                                     

By selected "I Agree" below, you are authorizing your signature to be taken electronically, which holds the same value as your written signature.

Waiver Signature:             I Disagree I AGREE