TED MOORE RUN/WALK REGISTRATION FORM

If you would like to donate to the Run/Walk you can donate here

Last Name:  Enter your legal last name  First Name:  Enter your legal first name  M:  Please enter your middle name or middle initial (Max of 12 characters). 
Street or P.O. Box:  Please enter your mailing address in this line. 
City:  Enter your city. 
State / Province:  Select your state from the drop down list. 
Zip Code:  Please enter your 5 digit zip code. 
Home Phone Area Code : Phone # Enter phone number without the -. 
Age : Enter your age. 
Gender: Male Female  Male or Female
Date of Birth: Enter your date of birth. 
Email Address:  Enter a valid e-mail address. 
T-Shirt Size?  Please select your T-Shirt Size 
I would like to participate in the 5K Run Walk  Walk or Run 
Registration Fee
$20 in advance, $25 day of race
Student Fee $10
 Please select your T-Shirt Size 
Are you a student?: Yes No  Please check yes or no. 
Name of College/School:
Are you an Alumnus of MVCC?: Yes No
Are you participating in the Law Enforcement Challenge?: Yes No
Name of Law Enforcement Agency:
(you must be an employee of the agency to participate)
Awards/Age Divisions: Awards will be presented to the top male and female finishers overall, and the top male and female finishers in the following age categories: 14 and under, 15-19; 20-24; 25-29; 30-34; 35-39; 40-44; 45-49; 50-54; 55-59; 60-64; 64-69; 70-74; 75-79; 80 and over.

Participants should sign in at the MVCC Jorgensen Field house beginning at 7:30am on Saturday, May 3rd. The Run/Walk will be conducted Rain or Shine.

For questions or additional information please contact: Deanna L. Ferro-Aurience at 315-731-5797 or email Deanna Ferro-Aurience.
Waiver and Release:
In consideration of being permitted to participate in the Ted Moore Memorial Run/Walk Event. I hereby for myself, my heirs, and my personal representatives assume any and all risks associated with this event. I further waive, release, discharge, and covenant not to sue Mohawk Valley Community College, the MVCC Foundation, its employees, sponsors, organizers, volunteers or other representative or agents or their successors and assigns for any and all injuries or damages of any kind whatsoever suffered as a result of me and/or my child taking part in the event and any related activities. I also agree to the use of any photo, film, or videotape of the event for any purpose. I also give my full permission for such first aid as deemed necessary to be provided to me or my child on the premises or prior to transport to a hospital for further treatment. I acknowledge and agree that I have read and fully understand the above important information, warning of risk, assumption of risk, and waiver and release of all claims. I agree that it is a waiver and release of liability.

TO PARENT/GUARDIAN OF APPLICANT UNDER 18 YEARS OF AGE: I have read the foregoing and agree to its terms as they pertain to the minor applicant, and further agree to waive, release and hold harmless the persons and entitles named above from all rights, claims and liabilities as above, and for loss of services, which I may be entitled to enforce on behalf of the minor applicant or derivatively.

You must be over 18 years of age OR the parent/legal guardian of a minor under 18 years of age in order to agree to the waiver and release.

By checking below, I understand and agree to the above waiver and release*

I Agree