Name: 
      Address: 
         City: 
        State:    Zip: 
        Phone: 
       E-Mail: 
Date of Birth:    Age on race date: 
       Gender: M F
   Shirt Size: M L XL XXL
    Entry Fee: $20 After 9/7: $25  ROCKS Members
    Entry Fee: $25 After 9/7: $30  Non-Members
    Entry Fee: $15 After 9/7: $20  Kids 15 & under
               In addition to my registration, enclosed is a tax deductible donation of $           
               I cannot participate, but enclosed is a tax deductible donation of $      
        Event: 5M Run 2M Walk
ROTC Team Member: YES / NO 

Team Name: 

Corporate Teanm Memebr; Yes / NO 

Team Name: 



Payment Method: Check Visa Mastercard American Express

Credit Card Number: 
Card Holder's Name:  exp date
Card Holder's Address: 
Card Holder's Signature: 
 

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 agree to abide by any decision of a race official relative to my ability to safely complete the run/walk. I assume all risks associated with running/walking in this event including, but not limited to: falls, contact with other participants, effect of the weather including high heat and/or humidity, traffic, and the condition of the road, all such risks being known 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 sponsors of the Rocks 5 miler & 2 Mile Walk, PVA, USATF, and other sponsors and their representatives and successors from all claims or liabilities of any kind arising out of my participating in this event even though 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, motion picture, recording, or any other record of this event for any legitimate purpose.

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