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| Name: _____________________________________ Age: ______ Sex: ______ Address: _______________________________________ DOB: _______________ (mo./day/yr.) City: _____________________________ State: ______ Zip: ____________ Phone: ___________________________ E-mail: __________________________ |
| ENTRY FEES: (check whichever fee is applicable) |
____ $16.00 - 5K entry fee for SVR members ____ $17.00 - 5K entry fee for non-members ____ $4.00 - Quarter mile kids run entry fee |
| WAIVER: In consideration of your accepting this entry, I, the undersigned, intending to be legally bound, hereby for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against any of the following: Chris Northrup, the Winchester Parks & Recreation Department, the Winchester Rotary Club, Shenandoah University, the City of Winchester, the Shenandoah Valley Runners and all additional contributors, sponsors and assigns for any injuries suffered by me in the scheduled March 29th, 2008 event. I attest and verify that I am physically fit and have effectively trained to complete this race. |
SIGNATURE: _________________________________ DATE: __________________ (Parent's or guardian's signature if under 18) |
| Please make checks payable to "Winchester Rotary Club", and mail to: |
| Rotary 5K & Kids Run c/o Chris Northrup Northrup Consulting 106 South Kent Street Winchester, VA 22601 |
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| The Rotary 5K Web pages are maintained by Karsten Brown. |
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