Great Pumpkin Entry Form:

First Name: ____________________________________

Last Name: _____________________________________

Male: _____ Female: _____

Age on Race Day: _______________________________

Address: _______________________________________

City: _____________________ St: ____ Zip:_______

Phone: _________________________________________

____ 5k Run

____ 1m Run

____ 5k Walk

____ 1m Walk

T-Shirt Adult

S___ M___ L___ XL___ XXL___

S___ M___ L___

___ $15 Adult Race Entry ($20 if late)

___ $10 Child (13 and under) ($15 if late)

___ add $5 for Outback Dinner for race participant

___ add $10 for Outback Dinner for non-race participant

Tickets for the Outback Dinner are on a first come, first served basis. Limited supply.

In consideration of your accepting this entry, I hereby waive all claims against Northwest Children's Home, associated sponsors, and any of their personnel for any injury I might suffer in this event or in route to or from the event. I hereby attest that I am physically fit and sufficiently prepared for completion of the event. Further, I hereby grant full permission for sponsors and organizers to include pictures of me and quotations from me in any legitimate accounts of the Great Pumpkin Race and in promotion thereof.

Signature: ____________________________

Date: ________________________________

Parent/Guardian (if applicant is under 18)

Signature: ____________________________

Date: ________________________________

Please make checks payable to "Northwest Children's Home" and return registration forms to the following:

Northwest Children's Home
504 E. Florida Ave.
Nampa, Id 83686