Last Name First Name Age on Sex
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__| |__|
October 17 M/F
5 MIle |__| Walk |__| Fun Run |__|
Mailing address (include apt. # and c/o)
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
City and State Zip/Postal Code
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |__|__|__|__|__|__|
Birth date Area Code Telephone
|___|___|___| |__|__|__| |__|__|__|-|__|__|__|__|
Mo Day Yr
E-Mail Address (optional for future race information)
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Fax Number(optional for future race information)
|__|__|__| |__|__|__| |__|__|__|__|
Shirt Size Youth small |__| Youth Medium |__| Youth Large |__|
Adult Small |__| Adult Medium |__| Aduit Large |__| Adult X Large |__|
| WAIVER. Knowingly and at my own risk I do hereby apply to enter an athletic contest. I hereby agree that I release and discharge the Pine Tree Apple Orchard, Vacation Sports, and other parties associated with the Run for the Apples 5 Miler from all claims, demands, injuries, damages, actions or causes of action from all acts of active or passive negligence on the part of such corporations, organizations, clubs, their servants, agents or employees, and hereby assume all the risks associated with my participation in the event. Further, I hereby grant full permission to any and all of the foregoing to use my name, likeness and voice, as well as any photographs, videotape, motion pictures, recordings and any other record of this event in which I may appear for any legitimate purpose including broadcast of the event, the reuse in any media of this broadcast and in advertising and promotion. |
|---|
Signature(by parent or guardian if
participant is under 18) ___________________________________________________
MAIL ENTRY FORM WITH $20 BY October 16 TO
No refunds