Name: 
       Address: 
          City: 
         State:    Zip: 
    Home Phone: 
    Work Phone: 
        E-Mail: 
 Date of Birth:    Age on race date: 
        Gender: M F
    Shirt Size: M L XL
         Event: 5K 10 Miler
     Entry Fee: $23 After Mar. 6 $30

 
   

In Consideration of my application being accepted, I hereby, for myself, my heirs, and executors waive, release, and forever discharge any and all rights and claims for damages,demands or actions which I may have or may hereafter accrue to me against the Reston 10 Miler, VA Runner, PVAC/USATF, Racepacket,Inc, South Lakes HS, and all sponsors of the Reston 10 Miler for any and all injuries suffered by me in any manner, in said event. I recognize that headphones,dogs,racing strollers, and inline skates are not permitted.

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Signature                        Date          Parent's Signature if under 18