20th Annual

Mike McAvoy/FWTC
PO Box 11703
Fort Wayne, IN 46860

 This entry form is intended to be printed for mailing only. Do not e-mail.

Name_______________________________Age___________

Address__________________________Date of birth________

City________________________State_______Zip_________

Phone______________E-Mail____________Sex: M F

Fort Wayne Track Club Member? Y N

All participants should bring non-perishable food item to benefit St Mary's Soup Kitchen.

Waiver:
I know that running a road race is potentially hazardous. I shouldn't enter and run or walk unless I am medically able and properly trained. I agree to abide by any decision of race officials relative to my ability to safely complete that run or walk. I assume all risks associated with running in this event including, but not limited to: falls, contact with others, weather effects, including high heat and/or humidity, traffic and the conditions of the road, all such risks being known and appreciated by me. For my safety I understand that bicycles, skateboards, baby joggers, roller skates/blades, animals, and radio headsets are not allowed in the race and I will abide by this guideline. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Fort Wayne Track Club, NE Indiana Dietetic Association, and all sponsors and all their representatives, successors and assigns, from all claims or liabilities of any kind arising out of my participating in this event though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver.

Signature______________________________Date_________

Signature______________________________Date_________
(Parent/Guardian signature required if under 18 years)