Name_________________________________________________________

Age__________     Sex _________

Check event:   _____ 5K     ___ 1 Mile Fun Run/Walk

Check if NAC Member:   ____ NAC Member

Street_______________________________________________________

City____________________________State__________Zip____________

e-mail_______________________________________________________

Phone_______________________________________________________

Tank shirt size: _____ Child    _____ Adult Large _____ Adult X-Large

I hereby asume all risks related to participation in the NAC Run/Walk. I release myself, heirs, and executors for injury or illness which may result from my participation. I further state that I am in proper physical condition to compete in the event.

Signature________________________________________

Parent/Guardian if under 18______________________________