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 First:_____________________________________________                                                                                      

 Last:_____________________________________________                                                                                       

 Address:_________________________________________                                                                              

 City:_____________________________________________                                                                                       

 St:_________        Zip:___________________                       

 

Birth Date d/m/y: ________ /________/__________                                           

 Male: ______    Female:_______                 

Phone:____________________________                                                                                 

 Email:                                                                                                                                                                                 

 TEAM NAME:_________________________________                                                                     

 Teams!   Team members must each fill out an entry form and submit together!

 
Circle One:                     Individual     Team of 2

January 1-31:                                      $20             $35

February 1-16:                                    $25             $45

 Late registration at Route 16 Running only!

February 17 & 18:                   $30             $55

Total Paid: $______________

WAIVER!  I warrant that I am physically able to participate in this event. In consideration for myself, my debtors, administrators and assignees, I do hereby release and discharge any rights and claims against Route 16 Running and Walking, Custom Race Systems, City of Gig Harbor, Dock Street Runners, USA Track and Field, and any other individuals or groups involved with the running of this event of any or all injuries suffered by me at this event or while traveling to and from the event. I also understand that in the event that You Knock My Socks Off 5k cannot be held as scheduled due to an act of God or other circumstances, I am not entitled to a refund of any money paid by me to participate. I also hereby consent to and accept responsibility for any emergency treatment in the event of injury or illness. I further grant permission to use my name, age, birth date, city, finish place, photo or likeness for publicity or post-race activities. This entry form serves as your receipt.

Signature:___________________________Date______________

Parent Signature if 18 yr or under __________________________Date__________
 
Make Checks Payable to:

Custom Race Systems

·         Mail to:

Route 16 Running and Walking,

C/o Knock My Socks Off

6745 Kimball Dr. Ste. EGig Harbor, WA 98335