Name: 

      Address: 

         City: 

        State:    Zip: 

        Phone: 

       E-Mail: 

Date of Birth:    Age on race date: 

       Gender: M F

        Size: M L XL 

    Entry Fee:  $20 after 11/1

    Team Name: 

Waiver Must Be Read and Signed Before Mailing:

I know that running a road race is a potentially hazardous activity and that I should 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 safely. I assume all risks associated with running in this event including, but not limited to: falls, contact with other participants, the effects of the weather, induding high heat and/or humidity, traffic and conditions of the road, all such risks being know and appreciated by me. 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 Road Runners Club of America, the race organizers, all sponsors their representatives and successors from all claims or liabilities or any kind arising out of my participation in this event or carelessness on the part of the persons named in this waiver. Further, I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for legitimate purposes.

_______________________________  _____________ _____________________________________

Signature                        Date          Parent's Signature if under 18

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