Women Can Run - Jonesboro Registration Form

Women Can Run Registration Form
Jonesboro Clinic Clinic leader Yalanda Young, 870-834-5067, yalanda.young@yahoo.com ________________
Information is required in all fields!
Last Name:
First Name:
Street Address:
City:
State:
Zip Code:
Telephone (Day):
Telephone (Night):
Email Address:
Date of Birth:
Age:
Emergency Contact:
Person Name:
Phone:
Select Training Group:
	Group 1 -- Walkers Your goal is to train to walk up to 3.1 miles (5 kilometers), and/or learn to walk longer and at a faster pace.
	Group 2 -- Beginning Runner Your goal is to train to run/jog up to 3.1 miles (5 kilometers). You are currently not running any, or not more than 3 minutes at a time.
	Group 3 -- Intermediate Runner Your goal is to train to run consistently up to 3.1 miles (5 kilometers). You are currently running at least 4 minutes at a time up to 30 minutes total.
	Group 4 -- Advanced Runner Your goal is to run longer distances and at a faster pace. You are currently running approximately 3 miles and have possibly run some 5K or 10K races. You want to increase your speed and run for longer distances.
Waiver, read carefully: Do not edit!	In consideration of the acceptance of registering and participating in this clinic, I, hereby, for myself, my heirs, executors, administratiors and anyone entitled to act on my behalf, release and discharge Women Run Arkansas Running/Walk Club, ArkansasRunner.Com, their representatives and successors, promoters, managers, directors, officials, agents, sponsors and their employees, members of the WRA club and volunteers of all of the Women Can Run Clinics from any and all claims of injury or liabilities of any kind, illness or damages suffered by me, as a result of my participation in or traveling to or from this clinic. I realize that walking, running and volunteering to work in the Women Can Run Clinics can be a potentially hazardous activity. I should not sign up to participate unless I am medically able. I agree to abide by any decision of the director or leader relative to my ability to safely complete the run/walk training session and graduation event. I assume all risks associated with walking, running, leading and volunteering to participate in or work in these clinics, including but not limited to falls, contact with other participants, the effects of the weather, including high heat and/or humidity, the conditions of the track, road and traffic on the course, all such risks being known and appreciated by me. I realize that this is a strenuous event which requires proper physical conditioning. I hereby certify that I am in such physical condition and good health to participate in this clinic. I also give my permission for the free use of my name and picture in any written account, broadcast or telecast of this event for any legitimate purpose.
Important note: This form will provide registration information only. On the date of your first attendance to the clinic, you must sign the waiver/medical release form. Anyone under the age of 18 must have a parent or guardian sign for them.

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