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Last Name First Name MI
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Street Address or P.O. Box No
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City State Zip
___________________ ___________________ __________
Date of Birth Age on Race Day Sex
Circle T-Shirt size S M L XL
Registration Fee:
$16.00 prior to May 27th
$20.00 May 27th through Race Day
Make checks payable to:
MAIN STREET ASSOCIATION
Waiver: In consideration of acceptance of this entry, I waive any and all claims for myself and my heirs against officials or sponsors of the Running with the King 5K for injury or illness which may directly or indirectly result from my participation. I further state that I am in proper physical condition to participate in this event.
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Runner's Signature Date
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Parent or Guardian if Under 18
(No Refund of Registration Fees)
Mail To:
Main Street Association
108 South Broadway
P.O. Box 468
Tupelo, MS 38802 - 0468
