Name (please print): _________________________ Gender: _____ Age on Race day________

Address: ___________________________________________

City/State ______________________________ Zip: _______________

Phone: ___________________ email: ____________________________

I will participate in the following event: ____5K Run _____ 5K Walk _____ 3K Kids’ race

Registration: Early Registration is prior to April 20, 2008

Make checks payable to: AMSW2

Mail to:

Gail Leedy

Division of Social Work

Dept. 3632

1000 E. University

Laramie, WY 82071

Early Registration: $15.00

Regular Registration: $20.00

Kids’3K Registration: $10.00

Early Student Registration (bring ID to event): $12.00

Optional donations to the Downtown Clinic are really appreciated!!

Yes, I would like to make a donation of $_______.

RELEASE AND WAIVER:

In consideration of the acceptance of this entry I hereby release the race directors and volunteers, along with any sponsors of the race, their officers, members, agents and employees from all actions, claims and demands of any kind that may arise from or in connection with my participation in any aspect of the Jackalope Loop for myself, my heirs and executors. I expressly assume any and all risks which might be associated with the Jackalope Loop, or with road racing. The signature of the parent on this RELEASE shall operate as a waiver and release of any and all rights and claims for damages which a minor child may have for damages of any kind whatsoever as a result of the child taking part in the race, walk, and any related activities.

Participant’s Signature: _______________________________ Date: __________

Parent/Guardian Signature (if under 18): _____________________________ Date: ____________