Name: 
      Address: 
         City: 
        State:    Zip: 
        Phone: 
       E-Mail: 
Date of Birth:    Age on race date: 
       Gender: M F
    Entry Fee: Postmarked by 7/14 $15 After 7/14 $18
     Donation: 

Waiver Must Be Read and Signed Before Mailing:

In consideration of your accepting this race entry, I, for myself, my heirs, executors, administrators and assigns, forever rlease and discharge any and all rights, demands, claims for damages and causes of suit or action, known or unknown, that I may have against Run for Research, and any and all participating race sponsors, their directors, officers, employees and agents of such parties, for any and all injuries in any manner arising out of my participation in said race. I attest and verify that I have full knowledge of the risks involved in the race, that I assume those risks, that I will assume and pay my own medical and emergency expenses in the event of an accident, illness or other incapacity, regardless of whether I have authorized such expenses, and that I am physically fit and sufficiently trained to participate in this race. I release the rights to any and all photographic material and computer information that the Run For Research may wish to release without obligation to me.

_______________________________  _____________ _____________________________________

Signature                        Date          Parent's Signature if under 18

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