First name:

Last name:

Address:

City, State, Zip:

Phone:

Email:

Class: Middle Freshman Sophmore Junior Senior College Coach Open

Age (Day of Race):

Team or Club (If Applicable):

T-Shirt Size (S/M/L):

Gender:

I/We, the undersigned, hereby certify that I/We am/are the parent/guardian of the player. In consideration of accepting this entry, I, the undersigned, assume full responsibility for any injury or accident which may occur during the event or while I am on the premises of the event. I hereby release and hold harmless the township of West Deptford, sponsors and race supervisory personnel. I verify that I am physically fit and have sufficiently trained for this running event and a licensed medical doctor has verified my physical condition. I hereby grant full permission to any and all of the foregoing to use any photographs, videotapes, recordings, and records of this event.

I have read and agree to all terms and conditions above:

Parent/Gaurdian Initials for Consent:

Comments:



Payment Send To:

Laxers 4 Life
111 Egg Harbor Rd, Suite B
Sewell, NJ 08080
(Please note: our address has changed)

Please make checks payable to: Laxers 4 Life

$20.00 Registration fee for all pre-registered runners.
$25.00 Registration fee for all race-day registrants.

Proceeds from the run will be donated to:

CUDDLE MY KIDS

If you are experiencing problems registering online, please email the required information to:

steve@ciprianicpa.com