Please print and complete form and mail to address listed below.
 
Last name ___________________________________________

First name____________________________________________

Mailing address________________________________________

City, State, Zip ________________________________________

Phone number ________________________________________

Email address ________________________________________
  

Age (as of 10/6/12) ____ Date of birth ____/____/____ Sex  M   F

Please circle:         5K run        5K walk

T-shirt size (long sleeve)    adult  S   M   L   XL    XXL

Waiver:  In consideration of acceptance of this entry, I waive any and all rights and claims for damages for myself and my heirs against River Valley High School and organizers, sponsors and volunteers of Nikki's Shortcut, for any injury or illness which may directly or indirectly result from my participation in this event.  I further state that I am in proper physical condition to participate in this event.  I authorize release of my name and picture for use in publication or advertisement of this event.  I understand the race will be held regardless of weather conditions and that registration is final with no refunds.  T-shirts are guaranteed only for those who preregister by September 21, 2012; t-shirts are not guaranteed to those registering after 9/21/12.  
Signature _______________________________Date ________
Parent/guardian signature if under 18 ______________________
Emergency contact name/phone # ________________________

Early registration fee                $18.00             before 7/8/12
Regular registration fee           $21.00             before 10/6/12
Day of race registration           $25.00
          
Please make check payable to Nikki's Shortcut and mail to :
Nikki's Shortcut, P.O. Box 233, Three Oaks, MI 49128 

You may purchase a sign that will be placed along the course for $5.00 with a message, ie words of encouragement, a joke, etc.
# signs _____ Message ________________________________
___________________________________________________
___________________________________________________

Thank you and we look forward to seeing you soon!