Sponsored by:


 

Name
First Name:   Middle Initial:   Last Name:  

Male
Female		 Age (on 11/22/2008   Date of Birth:   
Address
Street:   City:  
State:   Zip Code:
Phone:
Email:

In case of emergency, Contact: Name: Phone:

Event: Shirt Size:
thru 11/16/2008
$20
XXL Shirt
$3

Release and Waiver Statement (must be signed) I have read all information and understand the description of the event. I know that running and walking a road race can potentially hazardous activity. I should not enter unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete this event. I also know that while police protection will be provided, there may still be traffic on the course. I assume all risks associated with my voluntary participation in this event, including, but not limited to, falls, contact with other participants, effects of the weather, including extreme cold, ice , snow, heat, traffic, and all conditions of the road, all such risks to be known and appreciated by me. I agree that failure to return the IPECO timing tag at the conclusion of the race will result in a $30 fee. Knowing these facts, and in consideration of your accepting my entry, I for myself, my heirs, executors administrators, or anyone else who might claim on behalf, covenant not to sue and waive, release, and discharge Carmel Dad's Club, Northview Christian Life Church, Runners Forum of Carmel Inc., The End Result Co. Inc.,Carmel Police Dept.,Carmel Dept of Works, City of Carmel race officials, workers or volunteers, their representatives, successors or assigns for ANY AND ALL claims or liability, whether foreseen or unforeseen, for death, personal injury or property damage arising out of, or in the course of my participation in this event.
Signature of Participant:_______________________________________________________________

Signature of Parent or Gaurdian if under 18 years old:__________________________________

Fill out form in full, print and sign entry form, and then mail form and check or money order payable to Lawrence North Cross Country:
  Runners Forum
  620 Station Drive
  Carmel, IN 46032
Must be received by Aug 11, 2005

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