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Name: _____________________________Age on
race day: _______
Address:____________________________________________
City: _____________________ State: __________ Zip:_______
Phone: ________________ Sex: M ( ) F ( ) T-Shirt size: ( ) M ( ) L
( ) XL
Entry
Fees:
| Event (circle
applicable items) |
Postmarked before Oct.
3 |
Postmarked after Oct.
3 |
| 10K Run /10K Relay / 5K Walk |
$6.00 |
8.00 |
| Kid's Fun Run |
2.00 |
2.00 |
| Short sleeve T-Shirt (indicate size _____ ) |
9.00 |
9.00 |
| Long sleeve T-Shirt (indicate size _____ ) |
14.00 |
---- |
| Total Enclosed |
_______ |
_______ |
LIABILITY WAIVER: I know that
running a road race is a potentially hazardous activity. I should not enter and
run or walk this event 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 this event. I assume all risks associated with running or walking in
this event including, but not limited to: falls, contact with other
participants, the effects of weather, including high heat and/or humidity or
lightning, the conditions of the road and traffic on the course, all such risks
being known and appreciated by me. For my safety, I understand that bicycles,
skateboards, baby joggers, roller skates or in-line skates, animals, and radio
headsets are not allowed in the race and I will abide by this guideline. Having
read this waiver, and knowing these facts, and in consideration of your
accepting my entry in this race, I, for myself and anyone entitled to act on my
behalf, waive and release the Fort Wayne Track Club, all race officials and
volunteers, all sponsors, the Fort Wayne-South Bend Diocese, St. Louis Catholic
Church, St. Louis Academy, and all their representatives and successors from
all claims or liabilities of any kind arising out of my participation in this
event though liability may arise out of negligence or carelessness on the part
of the persons named in this waiver.
| _______________________________________________________________________ |
|
| Signature |
Date |
| _______________________________________________________________________ |
| Parent Signature if under 18 yrs. |
Date |
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