ENTRY FORM  --  NBSAC Beaches Challenge 5K Run & 2.5K Fun Walk --    RACE NO. ______

Make checks payable to and mail to:  --  USE A SEPARATE FORM FOR EACH PARTICIPANT --  (# assigned at check-in)

    N.B.S.A.C.                                                                                                        

   2004 Forest Ave., Neptune Beach, FL 32266

PRINT NAME  ____________________________   _________________________________

                                                 First Name                                                      Last Name

AGE (on Race Day): _____     CIRCLE SEX::  F    M        T-Shirt Size: ____        CIRCLE Category:   5k Run     Walk     City Official

REPRESENTING CITY OF _____________________________ AS _______________________             (If not circled, we will assume you are running) 

Email ___________________________________________________________________________          AMOUNT ENCLOSED: ______

ADDRESS ____________________________________________________ APT. _____

CITY ______________________________________________________ STATE ________ ZIP ____________

PHONE/EVE _______________   PHONE/DAY ______________  BIRTHDATE:  ___/___/___   

WAIVER: In consideration of this entry, I, the undersigned intending to be legally bound, hereby, for myself and anyone acting on my behalf, release any and all claims for damages I may have against the Neptune Beach Senior Activity Center, Festival organizers, City of Neptune Beach, City of Atlantic Beach, City of Jacksonville, Performance Multisports, the race directors, race staff, volunteers, and any sponsors and their representatives, successors and assigns for any and all injuries and death suffered by me in said event. I attest and verify that I know that a running competition can be a potentially hazardous activity. However, I have sufficiently trained for the completion of this event and know that I am participating at my own risk. I am also aware of the dangers of exercising or competing in hot weather and humidity. I have read this waiver of liability and accept the risks and responsibility associated with entering this event. I hereby grant permission for the free use of my name and picture in any broadcast brochure, or account of this event. I understand that by not pre-registering by the cut-off date listed online, I may not be able to get a souvenir T-shirt from this event.

Signature ____________________________________________________ Parent__________________________________________ Date ___________

If participant is under 18 years of age, parent or Guardian must sign.

For more information, Neptune Beach Senior Activity Center at 904/270-1688