Your Information

First Name:

Last Name:

Address 1:

City: State: Zip:

Phone:

Age:   Birthdate:

Email:

Sex: Male Female

My ChampionChip Number (if applicable):

I will use a chip provided by the race and will return it after the race. I understand that I will be assessed a $30 fee if I fail to return the chip.:
Yes, Please provide a chip for me N/A (I have a chip)

Are you an Attorney?: Yes No

5K Run or Walk?: Run Walk

Shirts

Size: Small Medium Large X Large
XX Large (add $2) XXX Large (add $3) XXXX Large (add $4)

Payment

Name on Card:
Card Type: Mastercard Visa

Card Number: Input number with no spaces

CV2: Input the last three digits from the back of your card. For AMEX, the 4 digits after your card number.

Expiration: 01 02 03 04 05 06 07 08 09 10 11 12 / (YYYY)

Billing Zip:

Please press the Submit Application button to send this information to the GCBA. We will contact you shortly to confirm the data and to obtaing your billing information.

By pressing 'Submit', you agree to the following Waiver:
In consideration of acceptance of my entry, I, myself, my executors, administrators, do hereby release and discharge the Genesee County Bar Association, Genesee County Bar Foundation, their members, the City of Flint, all sponsors, volunteers, supporters and spectators of the race for all claims of damages, injuries, demands, actions whatsoever in any manner arising from my participation in said event. I have been warned I must be in good health to participate in this event. Further, I hereby grant full permission to use my name and photograph for purposes of publicity and promotion, without payment of consideration. In filling out this form, I attest and verify that I have full knowledge of the risks involved in this event, understand my own liability, and do accept the restrictions.