Please Note: ONE registration form must be completed per participant.

Event Information

Quantity
Price
Total
5K Registration
X
$
25.00=
$
0

Contact Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*
Date of Birth (mm/dd/yyyy)*

Emergency Contact Info

Emergency Contact Name*
Emergency Contact Phone Number*

Tech Shirt Size

Tech Shirt Size*
  • S
  • M
  • L
  • XL

Walker or Runner?

Walker or Runner?*
  • Walker
  • Runner

Team Information

If so, what is the name of the team you're running with?

Submission

In consideration of the acceptance of my participation at the Ronald McDonald House 5K Race, I the undersigned, intending to be legally bound hereby, waive and release myself, my heirs, executors, and administrators and all rights and claims for damages, demands, and actions whatsoever, including negligence, which I may have against the Ronald McDonald House of Scranton, McDonald's Corporation, all sponsors, all participating volunteers and supporters and those entities, representatives, successors, and assigns, arising out of my participating at their event, including any and all injuries suffered by me as a result of my presence at this event. I certify that I am physically able to participate in this event. I authorize that Ronald McDonald House of Scranton may use such photographs of me with or without my name and for any lawful purpose, including such purposes as publicity, illustration, advertising, and Web content.

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

Security Code