12th Annual Pioneer Day Entry/Registration Form

May 3, 2008

Last Name___________________________First Name___________________________

Date of Birth______________________Sex M_____F______ Age on Race day_______

Address_______________________________________________________________

City______________________________State________________Zip______________

T-Shirt Size S____M____L____XL____ Runner ____________ Walker _____________

ENTRY FEE:

Pre-registration ; $12.00

Day of Race registration:  $15.00

Make checks payable to: Pioneer Day 5K, C/O Paul Miller Motors, P.O. Box 488, Melbourne, AR 72556

RACE RELEASE (Must be signed by participant/parent or guardian)

I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted to participate in this event. I am a voluntary participant in this event, and in good physical condition. I know that this is a potentially hazardous activity and I hereby assume full responsibility for any injury or accident which may occur during my participation in this event or while on the premises of this event. In consideration of acceptance of this entry, I waive and release any and all claims for myself and my heirs against the race organizers, the White River Road Runners, and any and all sponsors of this race from any liability or any loss, damage, or injury which I may incur as a result of my participation in this race. I further state that I have trained and I am in proper physical condition to participate in this race. This entry is not valid unless signed by entrant. If entrant is under 18 years of age, parent or guardian must sign entry form.

Signature__________________________________________Date__________________

Parent/Guardian Signature_________________________________Date______________

Entry form not valid without signature and will be returned. Parents must sign for children under 18. Must have one form per person with signature. Photocopies are acceptable.