5.11.2013 - Bay St Louis, MS

1. FIFTH ANNUAL 5K/10K HEALTH RUN/WALK
Saturday, May 11, 2013
RACE BEGINS AT 8 a.m. at Depot Way
ENTRANCE FEE $25.00 10K
$20.00 5K
$10.00 for Students
CUT HERE ---------------------------------------------------------------
MAIL FORM TO: PO BOX 2333, BAY ST. LOUIS, MS 39521
Please make checks payable to: Mind, Body & Spirit Foundation
ALL PROCEEDS GO TO THE MIND, BODY & SPIRIT SCHOLARSHIP FUND
$5.00 Off for Gulf Coast Running Club Members
GCRC Member? __Yes __NO
Age Category ~ Please Circle Your Category
Male: 12 and under, 13-19, 20-29, 30-39, 40-49, 50-59, 60 and Over
Female: 12 and under, 13-19, 20-29, 30-39, 40-49, 50-59, 60 and Over
Fifth ANNUAL 5K/10K HEALTH RUN/WALK
T-SHIRTS while supplies last
___ Small ___ Medium ___ Large ___ X-Large
NAME ____________________________________________________________________
ADDRESS _______________________________________ Telephone ________________
CITY __________________ STATE _____ ZIP ___ Sex ___ Age on Race Day __________
RACE PACKET PICK-UP
Friday, May 10th from 4 p.m. until 7 p.m. at Cypress Café
Saturday, May 11th from 6:30 a.m. until 7:30
This release and waiver is executed on this date April 1, 2013
Knowingly, and at my own risk, I am participating in the Mind, Body & Spirit 5K Run or the 1 Mile Fun Walk on Saturday, May 11, 2013 I do hereby waive
release any and all claims against the Bay St. Louis-Waveland School District or the Mind, Body & Spirit Foundation, and all event sponsors, employee,
volunteer, or officials of these organizations from any claim of injury (including death) that I may incur as a result of my participation in the event. I further
hereby certify that I have full knowledge of the risks involved in this event, and I am physically fit and sufficiently trained to participate. If, however, as a result of my
participation in the Mind, Body & Spirit 5K /10K Run or the Fun Walk on Saturday, May 11, 2013, I require medical attention, I hereby give consent to
authorize medical personnel to provide such medical care as deemed necessary.
______________________________________________________________________________________
Printed Name of Participant:
_______________________________________________________________________ ___________
Signature of Participant Today’s Date:
______________________________________________________________________________________
Printed Name of Parent or Guardian (If under 18 years of age):
_______________________________________________________________________ ___________
Signature of Parent or Guardian (If under 18 years of age) Today’s Date: