Name: 

      Address: 

         City: 

        State:    Zip: 

        Phone: 

       E-Mail: 

Date of Birth:    Age on race date: 

       Gender: M F       

   Shirt Size: S M L XL

    Entry Fee: $20

Waiver Must Be Read and Signed Before Mailing:

I know that running is a potentially hazardous activity. I should not enter and run or walk in the race 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 compete in the race. I assume all risk associated with participating including, but not limited to, falls, weather conditions, contact with participants, the effects of the road and traffic on the course, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, I, for myself and anyone entitled to act on my behalf, waive and release the Randi Joy Waxman Memorial Foundation, Michael Lichtenstein, the Montgomery County Road Runners Club, Columbia Union College, the City of Takoma Park, USATF, plus all event partners, sponsors and volunteers, their representatives and successors, from all claims or liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence 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 or any other record of this event for any legitimate purpose without compensation to me. For safety reasons, I agree not to run with: wheelchairs, strollers, pets, skates, or headphones.

_______________________________  _____________ _____________________________________

Signature                        Date          Parent's Signature if under 18

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