Viking Booster Club Fun Run / Walk Sunday, June 28, 2015 Meet at the Football Field / Track in Bertrand Registration at 7:30 a.m. Race Begins Promptly at 8:00 a.m. Official Entry Form (may be duplicated) One entry per person. Please complete all sections, SIGN & return this form with entry fee to: VBC Fun Run / Walk c/o Trista Newcomb 103 Medina Avenue Bertrand, NE 68927 Make checks payable to Viking Booster Club Entry fee is non-refundable. Contact: Trista Newcomb at 308-472-5327 cnewcomb1@frontiernet.net PLEASE PRINT: Last Name First Name Address City Age State E-Mail Address M Gender F Zip Phone Event (Mark One): 5K Run 2 Mile Run 2 Mile Walk 1 Mile Race (for ages 10 & Under ONLY) Entry Fee: $20.00 Age Division (as of 6/29/14, Mark One): 10 & Under (1 Mile Race Only) 15 & Under 16 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 49 50 - 59 60 & Over Register by Friday, June 12th to be guaranteed a T-shirt. Participants who register after June 12th are not guaranteed a T-shirt. Medals will be awarded to top male and female participants in each age division in each event listed above. T-Shirt Size (Circle One): Adult Size: Small Youth Size: Small (T-Shirts are guaranteed only to those participants who register by June 12th!) Medium Large X-Large Medium Large X-Large Waiver: (Parent or Guardian must sign if entrant is under age 18.) I hereby waive & release all rights & claims for damages I may have against the organizers & sponsors of the Viking Booster Club Fun Run / Walk event to be held on Sunday, June 28, 2015, for any & all injuries suffered by me in this event. I hereby authorize the organizers & support personnel of the Viking Booster Club Fun Run / Walk event to obtain any appropriate medical aid I may require during this event. I hereby grant permission for the use of my name and picture to be used in publicity or promotional materials and media coverage of the Viking Booster Club Fun Run / Walk event. Signature Date