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Name__________________________________________________________


Age_____ Birth Date______/______/______ Sex_____


Phone______________________ E-Mail Address_________________________________


Address__________________________________________________________________


City, State, Zip______________________________________________________________


T-Shirt Size:  S ____  M ____ L ____ XL ____ (T-shirts $10, will be delivered at 15 km)

I know that running in a 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. I assume all risks associated with running this event including, but not limited to, falls, contact with other participants, the effects of the weather, including high heat and/or humidity, traffic and the conditions 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 application, I for myself and anyone entitled to act on my behalf, waive and release the race organizers, the cities and towns in which this event is held, 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 that 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 pictures, recordings or any other record of this event for any legitimate purpose.

Signature________________________________________________________________