White River 5K Run & Walk Registration

Name: _____________________________________                      Male/Female  (circle one)

Address:_________________________________________________________

City, State and Zip Code____________________________________________

Phone______________________________ E-mail_______________________

Age on Race Day (June 26, 2004)_____________________________________

Early Bird Special (Postage Date 6/15/2004 or earlier)

               Includes T-shirt                                                                                  $20.00

               White River School District Employees/Students

               & Families Special Price (Before 6/15/2004)                                     $15.00

                Track and XC athletes and coaches from other high schools              $15.00

                 (Before 6/15/2004)

               *If  a student, which school do you attend? _____________________

               *If an employee, which building or facility do you work at?_____________________________________________________________________

            *If a parent, which school do your children attend? ________________

*This information will be used to award a trophy to the  group with the highest percentage participation.

            Day of race entry (no guarantee that a t-shirt will be available)               $20.00

T-shirt Size (circle)   X-small  small  medium          large    X-large  XX-Large

Hold Harmless Agreement: I assume all risks and hazards incidental to such participation and do hereby waive, release, absolve and indemnify, and hold harmless the White River Community Activities Program (WRCAP) and White River School District for any claim arising to myself and or my child. In absence of signature, payment of fee and participation in the program shall constitute acceptance of the conditions set forth in the release. Insurance for personal injuries or loss of personal property during any program/class/league/activity is NOT PROVIDED by the WRCAP.

Signature of Participant (parent/guardian if under 18)___________________________

Checks Payable to: Community Activity Program

Mail Registration and Hold Harmless Agreement to: Community Activity Program

                                                                                           P.O. Box 2206

                                                                                           Buckley, WA 98321