Name: Address: City: State: Zip: Phone: Todays Date: Date of Birth: Age: Event: 5K Run 5K Walk 30k Bike Shirt Size: S M L XL Division: M F Wheelchair Entry Fee: $20.00 by October 10 After 10/10 $25.00Additional Donation: I am contributing an additional $ .
I know that running a road race is potentially hazardous activity. I should not enter and run/walk/bike unless I am medically able and properly trained. I agree to abide the decisions of a the race officials relative to my ability to safely complete the run/walk/bike. I assume all risks associated with running in this event, but not limited to; falls, contact with other participants, the effects of weather, including high heat and/or humidity, traffic and 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 Ebenezer AME Church 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 liability may arise out of negligence or carelessness on the part of the person named in the waiver.
________________________________ ____________ ____________________________________ Signature Date Parent's Signature if under 18