Entry Form, Diversity 5000 (5K)

IUP-Punxsutawney, March 21, 2010, Registration @ 12:30, Start @ 2

Lunch and t-shirts to all participants

Name _____________________________________________________

Address ___________________________________________________

City, State, Zip _____________________________________________

Contact Name & Number in Case of Emergency

__________________________________________________________

Age on March 21, 2010 ______________________________________

E-Mail Address ____________________________________________

T-Shirt Size:   Small Medium Large  X-Large

Waiver: In consideration of your accepting my 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 Indiana University of Pennsylvania or Punxsutawney Borough and any other sponsors and their representatives, successors and assigns, for any and all claims and liabilities of any kind arising out of my participation in this event, even though the liability may arise out of the negligence or carelessness on the part of the persons named in the waiver. I agree to abide by any decisions of a race official relative to my ability to safely run/walk. I assume all risks associated with running/walking, including but not limited to falls, contact with other participants, the effects of weather, including high heat and/or humidity, traffic and the conditions of the road, all such risks being known and appreciated by me. I attest and verify that I will participate in this event as a footrace entrant and that I am physically fit and sufficiently trained for the completion of the event.

Participant Signature _________________________________________Date ____________

(NOTE –  Participants under the age of 18 require the signature of a parent or guardian) 

Entry Fee $10.00.  Make checks payable to IUP-Punxsutawney

Mail to: IUP-Punxsutawney, 1012 Winslow St. Punxsutawney, PA 15767

Attn. R. Beisel