Prime Inc Annual 5k or 1 mile fun walk/run- SPRIMO Sept 2nd 8am REGISTRATION FORM

Driver/User Code(Required)

Please list the name, age, gender, and event (5k or 1 mile) for the other person joining you

Example (John Doe, 20, Male, 5k event)

Please list the name, age, gender, and event (5k or 1 mile) for the second person joining you

Example (John Doe, 20, Male, 5k event)

Please list the name, age, gender, and event (5k or 1 mile) for the third person joining you

Example (John Doe, 20, Male, 5k event)

Please list the name, age, gender, and event (5k or 1 mile) for the fourth person joining you

Example (John Doe, 20, Male, 5k event)

Please list the name, age, gender, and event (5k or 1 mile) for the fifth person joining you

Example (John Doe, 20, Male, 5k event)

Waiver & Release

I confirm that I am in good shape, health, and condition. I don't have any medical condition or medical history that will affect my participation in this event. I acknowledge that this event requires physical activity and there are possible risks and danger. I release Prime Inc for any responsibility in case of an accident, illness, or injury. I grant Prime Inc permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. I HAVE READ AND UNDERSTAND THE ABOVE WAIVER & RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW.

Phone

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Prime Inc SPRIMO Fun Walk/Run Registration form 2023

Emergency contact

Waiver & Release

2740 N Mayfair Ave, Springfield, MO, 65803

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