Egg Nog Jog

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 without T-shirt. Race-Day Registration is $15.

________$22 Pre-registration with Long-Sleeve T-shirt. Race-Day Registration is $30.

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

Make checks payable to: "Egg Nog Jog"
Send to: Greg McCormick, 10119 Crosier Lane, Cincinnati, OH 45242
(Pre-registrations should be postmarked by November 24th, , 2007)

Waiver: In consideration of the acceptance of my entry, I hearby waive, discharge and release on behalf of myself, my heirs, executors and assigns, all claims of any nature, including but not limited to damages, demands, actions, whatsoever in any manner, arising from my participation in the Egg Nog Jog, and do hereby release the Egg Nog Jog, coordinators, staff, sponsors, workers, officials and volunteers from any claim whatsover arising from my participation in this event. I agree to abide by all the rules for participation, and acknowledge that the Egg Nog Jog may refuse or return my entry at its discretion. I attest and verify that I understand the risks involved in such a run/walk, and that I am physically fit and have trained adequately in preparation and I agree to pay for my own medical expenses in the case of an accident or illness regardless of whether I have autorized such expenses. I have noted any medical condition and/or emergency contact information of 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________________________

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