JULY 2, 2008	GROUNDHOG 5K RUN / WALK
Name
Address
City, State, Zip
Contact Name & Number in Case of Emergency
Age on July 2, 2008	Gender Male Female
E-Mail Address
T-Shirt Size ( guaranteed with preregistration)	Small Medium Large Extra-Large
Event	Run Walk
Entry Fee	$12.00 until June 26, 2008 $15.00 after June 26, 2008
Total Amount Enclosed

Please complete the above fields, print the form, read and sign the waiver, then mail to the address below with a Check or Money Order.

Waiver: By signature, I attest that I am physically fit and sufficiently trained to participate in this event. I have full knowledge of the risks involved. I further acknowledge that the race course contains uneven surface conditions, potholes, and curbs, which may create a risk; I further acknowledge that the race is on public roads and that vehicular traffic may be encountered, and I accept these risks. Therefore, in consideration of the acceptance of my entry, I for myself, my heirs, my executors, and administrators waive any an all rights and claims for damages I may have against the Punxsutawney Area Community Center, race sponsors, Punxsutawney Borough, and any individuals associated with this event and will hold them harmless for any and all injuries I may suffer in conjunction with this event. I have read and understand this liability release.

Participant Signature __________________________Date ______________
(NOTE - Participants under the age of 18 require the signature of parent or guardian)

 

PLEASE MAKE CHECKS PAYABLE TO:
Punxsutawney Area Community Center

MAIL TO: Punxsutawney Area Community Center, 220 N. Jefferson St., Punxsutawney, PA 15767

 

NOTE: The entire form above and the waiver must be printed out legibly, completed, and mailed to the Punxsutawney Area Community Center with the entry fee. If you are unable to make your browser print the above form legibly and completely, then E-Mail us at pacc@pennswoods.net or send a request to the above address or call (814) 938-1008 for an entry form.