Official Entry Form
Always In Our Hearts Run/Walk
Photo copies of this form will be accepted. One completed form per entrant.

Full Name:                                                                                
Address:                                                                                  
City:                                              State:        Zip:                  
Phone:                                                                                     
Age:           Birthdate:                                                            
Sex:       Male        Female

Select One:             5K Run
                                 1 Mile Family Walk

Select One:
Adult-Shirt Size:                                Child Shirt Size:
                   M                                               S(6-8)
                   L                                                 M(10-12)
                   XL                                              L(14-16)
                   XXL

Preregistered Cost:              Day of Event Cost:
       $20 Individual                        $25 Individual
       $12 child under12                  $15 child under 12
OR       Donation:                         

Name of Child to be remembered:
Name:                                                                                                
Phonetic:                                                                                          
If the name may be hard to pronounce please provide a phonetic spelling.
For example: Cindy Koenig / Cindy (Ka nig)

Memory Board

We encourage you to bring a picture of your child the day of the race. We aregoing to have a bulletin board with all of our children's pictures. We willreturn the pictures after the dedication ceremony.

Release Waiver
Please read and sign the following release form.

Knowingly and at my own risk, I hereby apply to enter the Always in OurHearts Run/Walk and do hereby waive and release any and all claims for damages that I may incur as a result of my participating in the event against Always in Our Hearts, Village of Big Bend, Town of Vernon, Waukesha County, all sponsors, volunteers, or officials of these organizations for said injuries. I further hereby certify that I have full knowledge of the risks involved in this eventand I am physically fit and sufficiently trained to participate. If, however, as a result in my participation of the Always in Our Hearts Run/Walk, I requiremedical attention, I hereby give my consent to authorize medical personnel to provide such medical care as deemed necessary by such authorized personnel.

                                                                                                            
ParticipantSignature                                             Date

                                                                                                            
GuardianSignature                                                Date
If participant is under the age of 18, a signature of legal guardian isrequired.

Mail form with payment to: Always in our Hearts, C/O DebbiePayne, N8460 Zimmerman Rd, East Troy, WI 53120