Address: ___________________________
City, State, Zip: ___________________________
Phone: ___________________________
Sex: ___________________________
T-Shirt size: ____________________________
Age: ____________________________ (As of race day.)
Team Competition: Yes No List other team members_______________________________________
________________________________________
Make Checks Payable To:
Run the Park
C/O Don Baumgartner
635 Floyd Drive
Versailles, IN 47042
Circle One:
runner walker masters
Waiver:In consideration of the acceptance of this entry, I, for myself, my executors, and assignees, do hereby release and discharge the Versailles State Park, Don Baumgartner, Jim Cole, and all sponsors, workers, officials, and volunteers from any claim whatsoever arising from my participation in this event. I understand the risks for such a run/walk and have trained adequately in preparation. I have noted any medical conditions on this entry form. I permit the use of my name and/or photograph for participating in this event for publicity.
Entry Signature_____________________________ Date:_________________
Parents signature if under 18:_________________________________________ Date: ___________
In case of emergency contact:____________________________ Phone No._____________________