Black Squirrel 5K Run and Fitness WalkOfficial Entry Form

Name: ___________________________________________________________________

Address:_________________________________________________________________

City, State, Zip:____________________________________________________________

Phone:____________________________________________________________________

email:__________________________________________________________@__________________________________

Sex:_____________Age on Race Day:____________

Race Division (check one only):

5K Run _________ 5K Walk_________

Entry Fee: (check only one)

________$10 Pre-registration (before 9/18/10)

________$15 Late Registration

Make checks payable to: Glendale Chamber of Commerce
Send to: Greg McCormick, 10119 Crosier Lane, Cincinnati, OH 45242
(Pre-registrations should be postmarked by 9/18/10)

WAIVER: In consideration of the acceptance of my entry, I hereby waive on behalf of my heirs, executors, and assigns, all claims of any nature arising from my participation in the Black Squirel 5K, and do hereby release the Glendale Chamber of Commerce, The Village of Glendale, New Balance Glendale, and all sponsors, workers, officials, and volunteers from any claim whatsoever arising from my participation in this event. I agree to abide by all the rules for participation, and acknowledge that the Race Committee may refuse or return my entry at its discretion. I understand the risks for such an event, and have trained aqequately in preparation. I HAVE NOTED ANY MEDICAL CONDITIONS on this form.

ENTRY SIGNATURE:_____________________________________________Date: __________________

Parent's Signature (if under 18): ____________________________________Date: ___________________

Emergency Contact: __________________________________________Phone________________________

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