Name: 
      Address: 
         City: 
        State:    Zip: 
        Phone: 
       E-Mail: 
Date of Birth:    Age on race date: 
       Gender: M F        Event: 5K 1K
   Shirt Size: Child's M L XL
 5K Entry Fee: $20 by 10/26  $25 after 10/26
 1K Entry Fee: $15 by 10/26  $20 after 10/26
    Donation:  Yes No  Amount: $____________

  

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. 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, 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 entry, I, for myself and anyone entitled to act on my behalf, waive and release the organizers of the Goblin Gallop 5K, JQF, USATF, and all other 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 understand I may not run with headphones, a dog or a baby stroller. 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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