Register for the 5k Run/Walk and Kids Dash

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Step 1 of 2

Registration Information

*One credit card transaction per registrant.

Registration Type*

Individual Walker ($25)

Individual Runner ($25)

Kids Dash ($10)

Additional Gift

I wish to make an additional contribution

Additional Gift Amount*

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Frequency – Monthly

Make this a monthly donation

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Frequency – Annual

Make this an annual donation

Total Donation Amount

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Designation

Your Information

Credit Card Details*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Title

Name*

First Last

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Participant Information

Name*

First Last

Gender*

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T-Shirt Size*

Birthdate*

Age on Race Day*

I understand that walkers may NOT run the course and will be disqualified. In consideration of this entry being accepted, I hereby, for myself and my heirs, executors or administrators, waive and release all rights and claims for damages I may have against MVH, the Town of Oak Bluffs and all sponsors for any and all injuries incurred before, during or after this race.

Further, I hereby grant full permission to any and all of the foregoing to use my likeness in all media including photographs, pictures, recordings or any other record of this event for any legitimate purpose.

I agree with the above statement*

I agree

Electronic Signature*

First Last

Today's Date*

Additional Details

Corporate

This is a donation from a corporation

Company Name*

Comments

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Admin

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Atlas Fund

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Atlas Appeal

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Atlas Event ID

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Page Info

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Referer

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Embed URL

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Form Controllers

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Recurring Controller

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Tribute Controller

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Anonymous Controller

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Corporate Controller

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Designation Controller

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Authorize.net

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Authorize.net Transaction Details

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Comments

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