Road Race Entry Form

First Name
Last Name
Street Address
City
State/Province
Zip/Postal Code
Home Phone
E-mail

Emergency Contact

First Name
Last Name
Home Phone

Waiver (This release of obligation must be signed)

In consideration of your accepting this entry form, I hereby for myself, my heirs, executors, and administrators, waive and release all rights and claims for damages I may have against the Fruitport 5,000 meter and 10,000 meter Road Race, the sponsors of these events, it's agents, representatives, successors, and assigners for any and all injuries suffered by me at said run, or which may arise out of my traveling to, participating in and returning from these events.

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Signature

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Parent's or Guardian's Signature - if under 18 years old

Complete, Print, and Properly sign the form. Enclose your check and mail to:

Old Fashioned Days Run
P.O. Box 74
Fruitport, MI 49415

or deliver to Lundberg's Storage Group in Fruitport (Formerly Lundberg's Hardware)
Hours:     M-F     9 am - 5 pm
            Sat    9 am - 2 pm

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