1. Since 2000, the Autism Assistance Fund has donated over $250,000 to support children with autism spectrum disorders in North Mississippi to provide hope to families and to give each child the best opportunity to reach their developmental potential. The goal of the Autism Assistance fund is to be funding source to groups and individuals so they can provide direct support for children affected by autism. Some of the ways this fund has made a difference includes: Primary donor to Camp BOLD; a three week summer day camp for children with autism. Has underwritten educational programs for teachers, parents, and children. Purchased IPads and educational apps for teachers for classroom use- Annually funds grants for special education teachers through he Desoto County Foundation for Excellence in Education. Financially supports autism awareness campaigns such as Light It Up Blue, Autism awareness Night with the Mississippi River kings, and other events. Encourages individuals and groups to submit grant requests to our grant committee in order to fund programs, which will positively affect these special children and their families. Hernando High school Interact Club, which is sponsored by the Rotary Club of Hernando, is made up of approximately 175 members and 2 sponsors. In April of 2012, the HHS Interact Club hosted the first “Light It Up Blue” event at Hernando’s historic square. This event brought over 50 people to the square in hopes of spreading autism awareness. It was this event that was the catapult for the club’s future projects. To further assist families in North Mississippi who have children with autism spectrum disorders, the HHS Interact Club will be hosting the 3rd Annual Bolt for Blue 5K on Saturday, March 28, 2015 at 9:00 a.m. at the Hernando Courthouse Square. All proceeds will be donated to the Autism Assistance Fund. RACE WAIVER AND RELEASE Must be signed by participant, parent, or guardian I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted in this event. I KNOW THAT THIS EVENT IS A POTENTIALLY HAZARDOUS ACTIVITY AND I HEREBY ASSUME FULL AND COMPLETE RESPONSIBILITY FOR ANY INJURY OR ACCIDENT WHICH MAY OCCUR DURING MY PARTICIPATION IN THE EVENT OR WHILE ON THE PREMISES OF THIS EVENT, AND I HEREBY RELEASE AND HOLD HARMLESS AND CONVENANT NOT TO FILE SUIT AGAINST……………HERNANDO HIGH SCHOOL, INTERACT CLUB AND ANY AFFILIATES OF THE SCHOOL, ANY RACE SPONSORS AND THEIR AGENTS AND EMPLOYEES, AND ALL OTHER PERSONS OR ENTITIES ASSOCIATED WITH THIS EVENT (THE “RELEASEES”) FROM ANY LOSS, LIABILITY OR CLAIMS THAT MAY HAVE ARISING OUT OF MY PARTICIPATION IN THIS EVENT, INCLUDING PERSONAL INJURY OR DAMAGE SUFFERED BY ME OR OTHERS, WHETHER SAME BE CAUSED Y FALLS, CONTACT WITH PARTICIPANTS, CONDITIONS OF THE COURSE, NEGLIGENCE OF THE RELEASEE OR OTHERWISE. If I do not follow all the rules of this event, I understand that I may be removed from the competition. I give my full permission to Hernando High School Interact Club, its local affiliates and races, and their sponsors and corporate sponsors to use any photographs, videotapes, or other recordings of me that are made during the course of this event. This waiver applies to all applicants on the registration form. ___________________________________________ Signature Date ___________________________________________ Parent/Guardian’s Signature if under 18 UNSIGNED ENTRY FORMS WILL NOT BE ACCEPTED ___________________________________________ T-SHIRT ORDER (Please write the quantity of each shirt) ADULT SIZES YOUTH SIZES ______Small ______Large ______Medium ______Large ______Small ______X-Large ______XX-Large

2. Event Location The 2015 Bolt for Blue 5K will be held at the Hernando Courthouse Square located at the corner of Commerce and Hwy. 51 in Hernando, MS. ___________________________________________ Race Day Schedule Saturday, March 28, 2015 7:30 a.m.-Late Registration 9:00 a.m.-Race Starts 10:45 a.m.-Results ___________________________________________ Entry Fees Before March 20 (by mail) and before March 24th (hand delivered to Hernando High School) $25 per person March 28 th (race day) $30 per person No refunds and no rain date ___________________________________________ Race Categories/Awards Top 3 Male Finishers Top 3 Female Finishers Top 3 Male & Female in Each Category 7 & under 25-29 50-54 8-10 30-34 55-59 11-14 35-39 60 and over 15-19 40-44 20-24 45-49 ___________________________________________ Pre-Registration Packet Pickup Hernando High School 805 Dilworth Lane Hernando, MS 38632 Thursday, March 26 th 8:00 a.m.—6:00 p.m. Friday, March 27 th 8:00 a.m.—6:00 p.m. T-shirts and packets are subject to availability. No t-shirts, numbers, or packets will be mailed. Make checks payable and mail to: Additional applications can be HERNANDO HIGH SCHOOL ENTRY FORM picked up at Hernando High c/o Angela Gregg INDIVIDUAL APPLICATION School, or runners can register 805 Dilworth Lane OR online at racesonline.com Hernando, MS 38632 FAMILY OF FIVE APPLICATION 1ST_____________________________________ ___________________________________________ LAST NAME FIRST NAME _________________________________________________________________________________________ ADDRESS _____________________________________ ___________ _________________________ CITY STATE ZIP _____________________________________ __________________________________________ DAY PHONE EVENING PHONE _______________________ __________ _______________ ______________ BIRTHDAY (MM/DD/YYYY) AGE MALE FEMALE 2ND_____________________________________ ___________________________________________ LAST NAME FIRST NAME _______________________ __________ _______________ ______________ BIRTHDAY (MM/DD/YYYY) AGE MALE FEMALE 3RD_____________________________________ ___________________________________________ LAST NAME FIRST NAME _______________________ __________ _______________ ______________ BIRTHDAY (MM/DD/YYYY) AGE MALE FEMALE 4TH_____________________________________ ___________________________________________ LAST NAME FIRST NAME _______________________ __________ _______________ ______________ BIRTHDAY (MM/DD/YYYY) AGE MALE FEMALE 5TH_____________________________________ ___________________________________________ LAST NAME FIRST NAME _______________________ __________ _______________ ______________ BIRTHDAY (MM/DD/YYYY) AGE MALE FEMALE