Veterans Memorial Park
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Last Name First Name MI
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Street Address or P.O. Box No City State Zip
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Date of Birth Age on Race Day Sex
Circle T-Shirt Size S M L XL XXL
Registration Fee: Make checks payable to:
$15 Now Until Race Day Crime Stoppers of Northeast Mississippi
$20 Race Day (No Refund of Registration Fees)
Waiver: In consideration of acceptance of this entry, I waive any and all claims for myself and my heirs against officials or sponsors of the 2010 Crime Stoppers Blue Steel Challenge 5K for injury or illness which may directly or indirectly result from my participation. I further state that I am in proper physical condition to participate in this event.
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Runner’s Signature or Parent/Guardian if Under 18 Date
Mail To: Dian Crawford Email: crimestop@ci.tupelo.ms.us
373 County Road 144 Fax: 662-840-5830
Tishomingo, Ms 38873