Cincinnati State Surge for Scholarships 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)

________$20 Pre-registration (Includes T-Shirt)

________$25 Race Day (Includes T-Shirt while supplies last)

T-Shirt size: (circle one if applicable) S, M, L, XL

Make checks payable to: "Cincinnati State""
Send to: Greg McCormick, 10119 Crosier Lane, Cincinnati, OH 45242
(Pre-registrations should be postmarked by October 13, 2007)

Waiver/ Release: (must be signed by participant): I understand that my consent to these provisions is given in consideration of the acceptance of this registration and for being permitted to participate in this event. I am a voluntary participant in this event, and in good physical condition. I know that this event is a potentially hazardous activity and I hereby assume full and complete responsibility for any injury or accident which may occur during my participation in this event or while on the premises of this event, and I hereby release and hold harmless and covenant not to file suit against Cincinnati State Technical and Community College and any race sponsors and their agents and employees, and all other persons or entities associated with this event (the "releasees") from any loss, liability or claims I may have arising out of my participation in this event, including personal injury or damage suffered by me or others, whether same be caused by falls, contact with participants, conditions of the course, negligence of the releasees or otherwise. If I do not follow all the rules of this event, I understand that I may be removed from the competition. give my full permission to Cincinnati State Technical and Community College and all sponsors to use any photographs, videotapes, audiotapes or other recordings of me that are made during the course of this event. I understand that this Waiver and Release may be stored electronically and agree that a copy is authentic and admissible as evidence in any future dispute or proceedings.

ENTRY SIGNATURE:_____________________________________________Date: __________________

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

Emergency Contact: __________________________________________Phone________________________

Back to Schedule