T-Shirt Size (If applicable) S  M  L  XL    Amount Paid: $ FREE to Active Duty


Payment Method:
  Please check one:
     Cashier's Check or Money Order (Enclosed)
     Check (Enclosed) - Make checks payable to MCCS. Social Security Number (SSN) is required to process all checks.
       ** If you check is received without a SSN, it will have to be returned.

     MasterCard    Visa        Discover
      Card Number             Expiration Date: (Month/Year) 
      
      Cardholder Signature: 


You can drop off your registration & check at the Devil Dog Gym, Marine Dome Issue Room & the Special Events Coordinator Office or mail it to: Special Events, Semper Fit Dept., MCCS, PSC Box 8009. MCAS Cherry Point, NC 28533-0009. Fax: (252) 466-1206 or DSN: 582-1206. For information call 466-2208 .
Credit card payment is also accepted. Must have company, type, address, card number & expiration date (Active Duty Only)

Entry Release: In consideration of acceptance of this entry, I waive any and all claims for myself and my heirs against the US Government, MCCS Directorate and all of their employees, volunteers and sponsors for any injury or illness that may directly or indirectly result from my participation in the above named race. I further state that I am in proper physical condition to participate in this event, and agree that none of the above parties is under any obligation to provide a physical examination or other evidence of my fitness to participate in the race, with this being my sole responsibility. I also give permission for the free use of my name and picture to any broadcast, telecast or written account of the event.

Signature:

Social Security Number #:

Parent's Signature (if under 18 years):

Active Duty Verification:
                                                                        MCCS Staff Only
Would you like to be contacted about future events?  Yes   No