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print in portrait format if possible Run for the Green 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: ________$22 Pre-registration with Long-sleeve t-shirt ________$15 Race Day ________$30 Race Day with Long-sleve T-shirts (while supplies last) T-Shirt size: (circle one if purchasing a shirt) S, M, L, XL Make checks payable to:
"Deerfield Township" Waiver/ Release: (must be signed by participant): 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 Run for the Green 5K Run/Walk and do hereby release Deerfield Township, Greg McCormick, Running Time LLC, USATF, 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 a run and have trained adequately in preparation. I have noted any relevant medical conditions on this form. ENTRY SIGNATURE:________________________________________________________________Date: __________________ Parent's Signature (if under 18): ___________________________________________________________Date: ___________________ Emergency Contact: ___________________________________________________________________Phone_____________________ Relevant Medical Condition _____________________________________________________________________________ |