22nd Annual "Make It To The Line" 4-Mile Run/ Walk & 1-Mile Fun Run
Saturday, December 19, 2009

Please fill out the form below by typing in your responses, print it out and mail to:
"Make It To The Line" Race
c/o Flora-Bama®
17401 Perdido Key Drive
Pensacola, FL  32507

Individual Registration Family Registration
3 Members Only
Each member must fill out a separate application.
$20.00 Before December 3rd
$25.00 After December 3rd
$30.00 Day of Race		 $48.00 Before December 3rd
$60.00 After December 3rd
$75.00 Day of Race
4-Mile Run 4-Mile Walk Wheelchair Fun Run
First Name Last Name
Male     Female Age: Birthdate:  MM DD YY Phone Number --
Shirt Size: Small Medium Large X-Large XX-Large
Mailing Address:  Apt. or Unit #: 
City:  State:  Zip Code: 
E-Mail Address: 

Release (Mandatory): In consideration of accepting this entry, I, the undersigned, intending to be legally bound, hereby for myself, me heirs, my executors and administrators, waive, release and discharge forever, the Flora-Bama® Lounge and all persons organizing or conducting the “Make It To The Line” Race and its sponsors, agents, servants, representatives, licensees, contractors, successors and assigns, from any and all claims, demands, rights and causes of action, regardless of the nature, resulting directly or indirectly from any and all known or unknown, foreseen or unforeseen, bodily or personal injury, damage to property and the consequences thereof resulting from my running and/or participating in said “Make It To The Line” race on December 19, 2009 and agree not to sue for any said injuries and/or damages. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event. Further, I hereby grant full permission to any and all foregoing to use photographs, videotapes, motion pictures, recordings or any other record of this event for any purpose whatsoever.

_________________________________ ________
Signature (Parent or Guardian's Signature if under 18 years of age) Date

Office Use Only

Check # ________

Amount $ ________

Received: ________