Name:
____________________________________ Age: _______
Address:
____________________________ City: _____________
State:
________ Zip: ____________ Phone: (
) ____________
Email:
_______________________________________________
Gender:
M or
F
Shirt Size: Sm
Med Large
XL
On
or Before April
5th
Individual with Shirt -
$12.00
Individual without Shirt -
$7.00
After
April
5th
Individual with Shirt - $15.00
Individual without Shirt -
$10.00
PLEASE READ THE
FOLLOWING STATEMENT AND SIGN BEFORE SUBMITTING ENTRY.
I know
that running a road race is a potentially hazardous activity.
I should not enter and run unless I am medically able and properly
trained. I assume all risks
associated with running in this event, including, but not limited to falls,
contact with other participants, the effects of weather, traffic, interaction
with non-participants and the conditions of the road all such risks being known
and appreciated by me. Having read
this waiver and knowing these facts and in consideration of the acceptance of my
entry, I, myself and anyone entitled to act on my behalf, waive and release any
and all sponsors and organizers, their officers, agents and assigns, the race
director and volunteers from all claims or liabilities of any kind arising out
of my participation in this event even though that liability may arise out of
the negligence or carelessness on the part of the persons named in this waiver.
I also understand that my entry fee is non-refundable and
non-transferable. A parent must
sign if the child is under 18 years of age.
This certifies that the child has permission to participate and agrees to
the previously stated waiver.
Signature:
_________________________ Date: ______
Signature:
_________________________ Date: ______