Name of Honoree as you wish to see it on the t-shirt

First Name *

Last Name *

5K or Memory Walk * Select 5k or Memory Walk 5k Memory Walk

Gender * Select Gender Male Female

Age on Race Day *

Team Name (if applicable)

Address *

City *

State *

Zip *

Phone *

Email *

T-Shirt Size * Select T-Shirt Size Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult XL Adult XXL None

I hereby waive all claims against the race director, race officials and volunteers, any and all sponsors including, but not limited to Homeland Hospice, Homeland Center, the Rossmoyne Business Center, the County of Cumberland, and all its representatives and successors from any injury or liability I might suffer in this event. I attest that I am physically fit and prepared for this event. I assume all risks associated with running in this event including, but not limited to: falls; contact with other participants; the effects of the weather, including high heat and/or humidity; and the condition of the road; all such risks being known and appreciated by me. I grant full permission for organizers to use my name and or pictures in legitimate accounts and promotions of this event. *

Electronic Signature *