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print in portrait format if possible Legacy "Rock N Run" 5K 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) ________$25 Race Day (Includes T-Shirt while supplies last) ________$10 Extra Dinner Tickets T-Shirt size: (circle one if applicable) S, M, L, XL Make checks payable to:
"Legacy" 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 Legacy "Rock N Run" and do hereby release the Legacy, Greg McCormick 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 that the risks for such a run and have trained adequately in preparation. I have noted any relevant medical conditions on the back of this form. I permit the use of my name and picture participating in this event for publicity. ENTRY SIGNATURE:_____________________________________________Date: __________________ Parent's Signature (if under 18): ____________________________________Date: ___________________ Emergency Contact: __________________________________________Phone________________________ |