First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Cell Phone

Your Age:*

Please indicate below what size shirt*

Entry fee of $20

Contactless indicates you will mail in the registration form with the fee and we will mail you your packet. This option is an extra $2.50 for postage. If contactless is not selected, it will be assumed you will come by and pick up your package at the shelter.

If mailing in form I will I send to the following Randolph County Humane Society Attn: Stuttin Mutts P.O. Box 59 Sparta Il 62286

Registration forms will be accepted until race starts but must be submitted by October 1st to guarantee a shirt. Packets will be available for pickup anytime after October 7th. Packets will be mailed out by October 7th.

By typing your name in the following box you agree to our Release of Liability as follows. I know that running/walking in any type of race has the potential hazardous activities including but not limited to heart exhaustion/stroke, falls, contact with other racers/animals, effects of weather and dangerous traffic conditions. I hereby agree, for myself and my heirs, personal representatives, executors and administrators to waive and release Randolph County Humane Society and its officers, employee and volunteers any and all sponsors, suppliers and any other personnel assisting or connected with this event.*