Derby Dash 5K Run/Walk Official 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)

________$15 Pre-registration (no T-Shirt)

________$20 Pre-registration with T-Shirt

________ $15 Seniors 65 and over with T-Shirt

________FAMILY DEAL: $20 first person, $5 each additional immediate family member (includes shirt)

________GROUP DEAL: $15 each (includes shirt). 10 people minimum per group. Must register together. Each person on a seperate form.

________$25 Race Day (No T-Shirt) (T-shirts will be available on race day for $10)

T-Shirt size: (circle one if applicable) S, M, L, XL, XXL, 3XL

Make checks payable to: FFLAG
Send to: Greg McCormick, 10119 Crosier Lane, Cincinnati, OH 45242
(Pre-registrations should be postmarked by April 28, 2012)

WAIVER/RELEASE: In consideration of the acceptance of my entry, I hereby waive, discharge and release on behalf of myself, my heirs, executors and assigns, all claims of any nature arising from my participation in the Derby Dash, and do hereby release the Fitness for Life Around Grant County, the city of Williamstown, all sponsors, workers, officials and volunteers from any claim whatsoever arising from my participation in this event. I agree to abide by all rules for participation, and acknowledge that FFLAG may refuse or return my entry at its discretion. I understand the risks involved in such a run/walk, and that I am physically fit and have trained adequately in preparation. I also give my permission to Fitness for Life Around Grant County to use any photographs, video or other recordings of me that are made during the course of this event. I also understand that my information (name, age, city of residence) may be posted online and/or in other media when posting the results of the run/walk.

ENTRY SIGNATURE:_____________________________________________Date: __________________

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

Emergency Contact: __________________________________________Phone________________________

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