5k pre registration form

PRE-REGISTRATION ENTRIES MUST BE POSTMARKED BY MARCH 20, 2010. RACE DAY REGISTRATION IS FROM 7:30AM-8:30AM AT THE SHELTER HOUSE. ANY QUESTIONS? E-MAIL US AT sthenryems@live.com
Mail completed form and check to: St. Henry Squad, P.O. Box 6, St. Henry, Ohio 45883
Name_________________________
Address_______________________
City, State, Zip__________________
Telephone _____________________
E-mail ____________________________
Age ( as of April 3, 2010) __________
Sex: Male___ Female_____
Pre-registration entry fees ( please circle one )
5k with shirt $ 15.00 5k only 8.00
***day of race fees are different***
TOTAL AMOUNT DUE $___________
T-shirt Size ( adult ) S M L XL XXL
In consideration of the acceptance of my entry, I for myself, my executors, do hereby release the St. Henry Squad, Race officials, Sponsors, and Volunteers from all claims to damages, demands, actions whatsoever in any manner arising or growing of my participation in said event. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in this event. I also give permission for First Aid. I authorize the use of my name and/or photo to be taken at thsi race for use in any news media or any form of publicity.
Signature____________________________ Date______
(all entries must be signed!)
If registrant is under 18 years old, a parent (legal guardian) must sign
BIB #________