JOLLY JINGLE JOG REGISTRATION Participant InformationParticipant Name* First Last Participant Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Gender Shirt Size (S/M/L/XL) Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian InformationParent/Guardian Name First Last Parent/Guardian Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Participant or Parent Email Address* Parent Cell NumberEmergency Contact Name* First Last Emergency Contact Relationship* Emergency Contact Phone*WaiverI understand that I am registering for the Jolly Jingle Jog 5K for myself or my child and must read, agree to and sign this agreement where I assume the risks for participation, waive of liability, and Jolly Jingle Jog policies and procedures. I understand that the Jolly Jingle Jog is voluntary. I or my child may walk, jog or run this event and do so at the participant's own risk. I understand that this event takes place, in part, on a public road that is not closed to automobile and other traffic. I understand it is up to me to decide what is appropriate for me or my child when participating in the Jolly Jingle Jog. I acknowledge that I or my child either has had a physical exam and has been given a physician’s permission to participate or I have decided to allow my child to participate without approval of a physician. I understand that I have the complete right to stop or decrease mine or my child’s participation in the Jolly Jingle Jog at any time during the event. I understand that the Jolly Jingle Jog is a non-competitive community event that is not staffed with medical professionals. I realize that participation in walking or running event may include, due to my own choice, strenuous exertion which will increase heart rate and body temperature. I understand that exercise involves certain risks, including but not limited to, serious neck and spinal injuries resulting in complete or partial paralysis, heart attack, stroke or even death. Also, injuries could occur to bones, joints or muscles. Slips, falls, and unintended loss of balance could result in muscular, neurological, orthopedic or other bodily injury. I understand that part of the risk involved in undertaking any activity or program is relative to my or my child’s own state of fitness or health (physical, mental, or emotional) and to the awareness, care and skill which I or my child conducts myself/himself/herself in that activity or program. Knowing the material risks and knowing and reasonably anticipating that other injuries are a possibility, I hereby expressly assume all of the delineated risks of injury, all other possible risk of injury, and even risk of possible death, which could occur by reason of my or my child’s participation. I do hereby waive, release and forever discharge Total Strength Fitness, Crow River Christmas, and the City of Rockford, Minnesota from any and all responsibilities or liability for any present and future injuries or damages resulting or arising from my or my child’s participation in the Jolly Jingle Jog. I AGREE AND UNDERSTAND.* Initial Here.Jolly Jingle Jog Policies and Procedures1. The Jolly Jingle Jog does not charge a fee to participate in this event. However, we do request that you bring a food or other donation for the RiverWorks Food Shelf in Rockford, MN. 2. The Jolly Jingle Jog is not a race, so no prizes are awarded for any place finish. 3. All participants are required to register for this event. 4. Any participant under the age of 18 must have parent/guardian permission to register and participate. I AGREE AND UNDERSTAND* Initial HereParent/Guardian AgreementI declare that I have read, understand and agree to the contents of this Jolly Jingle Jog Registration and Agreement in its entirety. I understand that the Assumption of Risk, Waiver of Liability, and Jolly Jingle Jog Policies and Procedures are intended to be as broad and inclusive as permitted by the State of Minnesota and agree that if any portion is held invalid, the remainder will continue in full force and effect. Signature*Please provide signature via touchscreen, touchpad or mouse.PaymentNo payment is required for the Jolly Jingle Jog 5K Fun Run. We only ask that you bring a donation for the RiverWorks Food Shelf the morning of the race. Thank you! CommentsThis field is for validation purposes and should be left unchanged.