Entry Form for Clark Potato Days Mile Walk / 5K Walk or Run / 10K Run
WAIVER: In consideration of your acceptance of this entry, I hereby release the sponsors! organizers of this event from any damages, liability or injuries suffered by me as a result of my participation in this event. I attest and verify that I have full knowledge of the risks involved and I am physically fit and sufficiently trained to participate. I also give permission for the free use of my name and picture in any broadcast, telecast, or print media account of this event.
Only one participant per entry form, please. You may use photocopies. Make Check Payable to: CHS Fieldhouse Fund.
Name: _____________________________________ Phone: ________________________________________ Address_______________________________________
_________________________________________ Signature: __________________________________________
Please Circle: Male Female Age Division: 19 & Under 20-29 30-39 40-49 50+
T-Shirt Size: S - M - L - XL Event Participating in: Mile Walk 5K Walk 5K Run 10K Run
Signature of Parent/Guardian ______________________________________
NOTE: All entrants under 18 must have the entry form signed by a parent
Mail form and entry fee to: Dacotah Bank /113 N Commercial Street / Clark SD 57225 / Phone: 605.532.3626 I Fax: 605.882.8398