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Freedom Run Registration Form

Print and complete this form. Please submit separate forms for each participant. Send it along with registration fee to address on form Or register online by selecting an event below:

• Open Runs
• Individual Walkers
• Small Family Walkers (2-5 people)
• Medium Family Walkers (6-9 people)
• Extended Family Walkers (10-15 people)

Name	First	Last
Male    Female
Address (Include Apt. No.)
City
State		Zip Code
E-mail
Telephone

I will be
Running 2 miles in age division
13 & under  14-19  20-29  30-39  40-49  50-59  60-69  70-79 80 & older
Running 5 miles in age division
13 & under  14-19  20-29  30-39  40-49  50-59  60-69  70-79 80 & older
Walking (Family name, if entering as family)
(Please staple all family member registrations together and send with the fee.)
Tank Top size (check one)               Youth   (size 10-12)                       Men's Cut     S       M      L       XL       XXL              Women's Cut     S       M      L       XL       XXL               (Tank tops guaranteed to every participant who registers before June 19, 2009.)
Circle One:       Master Card       Visa	Amount $ __________________
Number:   ________-________-________-________	Expiration Date: _________/_________

In consideration of the foregoing, I for myself, my executors, administrators, and assignees do hereby release and discharge St. Nicholas Hospital, the City of Sheboygan, Sheboygan Police Department, the Sheboygan County YMCA, and all other entities and individuals who are in any way connected with the event from any liability or claims for damages, injury, or illness arising or growing out of my participation in the St. Nicholas Hospital Freedom Run.  I represent that I have adequately trained and am medically able to participate in this event, recognize the risks of injury that accompany such participation, and acknowledge that this release is being relied upon by St. Nicholas Hospital in permitting me to participate. I grant full permission without compensation to St. Nicholas Hospital to use any photographs, recordings, or other reproductions of me participating in this event.