Name:  
       Address:  
          City:  
         State:    Zip:  
         Phone:  
        E-Mail:  
 Date of Birth:    Age on 12/31:  
        Gender: M F 
    Shirt Size: M L XL 
     Entry Fee: $19 After 12/11 $25  
  
 

I know that running is a potentially hazardous activity. I have read the race flyer and am familiar with the course. I will not enter and run unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running or walking in this event including but not limited to: falls, contact with other participants, effects of weather, traffic and road conditions. All such risks are known and appreciated by me. In the event that the race must be canceled due to weather, I agree that my entry fee will not be refunded but I may either pick up my t-shirt at MADD or treat my entry fee as a donation to MADD. If the race is canceled, notice will be available at 703-379-1135 by 3:40 pm race day. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the race directors, race beneficiaries, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event, even though such liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to all of the foregoing to use any photographs or any other record of this event for any legitimate purpose.

 Total Money Enclosed ______________________________

_______________________________ _____________ _____________________________________
 Signature                        Date          Parent's Signature if under 18