1. Healthcare

MOORPARK
GROUNDHOG DAY
5K Road Race and 1 Mile Fun Run Registration Form
Saturday, February 7th, 2015 at 8am
Fun Prizes • Medal for all Finishers 11 years and Under • 1 Mile Run held on High School Track
Special Pricing for MUSD Students!
Register online: www.moorparkgroundhogday5k.org
use Promo Code “MUSD” for $5 discount!
First and Last Name ______________________________________
Address________________________________________________
Registration Prices
Circle One
5K
1 Mile
City________________________________ State____ Zip _______
Now - Dec 15th
$25
$15
Email Address___________________________________________
Dec 16th - Jan 15th
$30
$20
Phone (Emergency Use Only)_______________________________
Jan 16th - Race Day
$35
$25
Male __ Female __ D.O.B. ___________ Age on Race Day ______
T-Shirt Size - Circle One
Emergency Contact_______________________________________
YS YM XS S M L XL
Phone #______________ Relationship to Participant ____________
Please register me for the 5K
1 Mile Fun Run
T-shirt guaranteed if
registered by Jan 15th
Age 11 and Under
Mail completed form and checks payable to Moorpark High School, 4500 Tierra Rejada Road, Moorpark, CA 93021
WAIVER: In consideration for being permitted to participate in the Moorpark Groundhog Day 5K, I hereby for myself, my heirs and personal representatives assume any and all risks,
which might be associated with the event. I further waive, release, discharge and covenant not to sue Moorpark High School, Moorpark Unified School District, or the City of Moorpark for
any injuries or damages I may suffer as a result of my participation in the Moorpark Groundhog Day 5K and related events. I hereby consent to receive medical treatment which may
deemed advisable during the event and understand that I am solely responsible for all costs related to the medical transportation and /or evacuation. I will additionally permit the use
of my name and pictures in broadcasts, telecasts, newspapers, brochures and etc., and I also understand that the athlete identification numbers are not transferable. As a participating
athlete, I certify that I am in good health, and able to participate in this event and that all information provided on this form is true and complete.
I HAVE READ AND UNDERSTOOD THIS RELEASE, WAIVER OF LIABILITY, AND INDEMNITY, AGREEMENT.
Signature _____________________________________ Printed Name ________________________________________ Date ___________(Parent or Guardian, if under 18 years old)