$12.00 pre-registration

$10.00 under 18 years of age

$10.00 per person Family Rate

(3 or more same family members)

In person or mail to:

Tricia Larremore

IWSM

210 W. Hospital Drive

Hattiesburg, MS 39401

By mail, postmarked no later than December 22, 2006

Long sleeve 100% cotton t-shirt

Pre-registrants guaranteed shirt on race day

1^st Male & Female Overall and Masters 40+

1^st, 2^nd, & 3^rd in each age group for men and women:

19 & under 40-49

20-29 50-59

30-39 60 & over

(Please Print)

Name: ____________________________________________________________ Last First

City: _________________________________Zip Code_______

I desire to participate at the Institute for Wellness & Sports Medicine. I agree to RELEASE AND FOREVER DISCHARGE, AS WELL AS PROTECT, INDEMNIFY AND HOLD HARMLESS, the Wesley Medical Center, LLC and the Institute for Wellness and Sports Medicine and all its parent companies, partners, subsidiary companies, agents, successors, officers, directors, servants, assigns, attorneys, representatives and employees from any and all liability arising out of my use of the grounds and facilities.

I further state that to the best of my knowledge, I am in good physical and mental condition to participate in exercise, I am not aware of any condition that would prevent me from physically or mentally participating in exercise, nor am I presently under the care of any physician for any medical condition that would prevent me from participating in exercise.

I understand that exercise activities I wish to start have certain risks. The reaction of the heart, lungs, and blood vessel system to such exercise cannot always be predicted with accuracy. I know that there is risk of certain abnormal changes occurring during or following exercise that may include, in rare instances, heart attacks. Use of weight lifting equipment and engaging in heavy body calisthenics can lead to musculoskeletal strains, pain and injury if adequate warm up, gradual progression and safety procedures are not followed

I have read the foregoing information and all questions, which may have occurred to me, have been answered to my satisfaction. I am free to deny answers to specific items or questions during interviews or when filling out questionnaires. The information, which is obtained, will be treated as privileged and confidential and will not be released or revealed to any person without my expressed written consent. The information obtained, however, may be used for statistical or scientific purposes with my right to privacy retained.

Signature of Participant: ___________________________________________________Date:___________________

Signature of Parent or Guardian:____________________________________________ Date:___________________