“Hustle for Hunger” 5K Walk/Run Registration Form

Full name:

Street Address:

City: State: Zip Code:

Age on race day: Sex:

Phone: (in case we need to contact you for problems with your entry)

Email: (for registration confirmation)

Do you plan on (Please ÃÈÅÃË):     Running OR      Walking

Projected TOTAL time for 5K (3.1 miles): Minutes (if running)

*NOTE: Runners with a blank estimated time will start in the final wave

*NOTE: Only pre-registered runners/walkers are guaranteed a T-shirt

ENTRY FEES:

• Children (10 and under)- $10 if paid before the event; $15 day of • Students (11 to 21)- $15 if paid before the event; $20 day of • Adults (22 and up)- $20 if paid before the event; $25 day of

*All pre-registered runners/walkers must mail their registration form with the signed liability and photo release forms in an envelope to the address below NO LATER THAN MARCH 17th. “Hustle for Hunger” 5K Walk/Run Janki Patel 563 North Gates Ave Kingston, PA 18704 *Make checks payable to: Leadership Wilkes-Barre (“Hustle for Hunger”)

All proceeds and funds will be donated to the Vincent de Paul organization in Wilkes-Barre.

RECORDED VIDEO PERFORMANCE RELEASE

I, , hereby grant Leadership Wilkes-Barre, and its agents the right to photograph/video/audio tape my likeness, voice, and performance (if applicable) at the “Hustle for Hunger” 5K Walk/Run, hosted by Leadership Wilkes-Barre on March 24th, 2013, and that said video/audio tape may be broadcast or otherwise transmitted by Leadership Wilkes-Barre, its successors or assigns. I agree that you may copyright said video/audio tape and/or pictures.

I further agree that my name, likeness, voice, and biographical material (if any provided) may be used in connection with publicity about “Hustle for Hunger” 5K Walk/Run.

I release Leadership Wilkes-Barre and its agents, successors, and assigns from further claims or demands arising from the uses of materials you may record, video, or photograph in which I appear or can be heard.

Participant’s Full Name (Please Print):

Participant’s Signature:

Parent/Guardian Full Name (Please Print):

Parent/Guardian Signature:

Date: