Valley YMCA

In consideration of my entry being accepted intending to be legally bound, I do hereby for myself , my heirs, executors, and administrators waive, release and forever discharge any and all rights for claims and damages, which may have and herein after accrue to me against the Valley YMCA, 5K Run, officer, members, games director and/or agents which may be sustained and suffered by me in connection with my association with or entry in this Valley YMCA 5K run.


PRINT OUT THIS APPLICATION AND MAIL WITH CHECK


CIRCLE EVENT:      5K                  2 Mile Walk

LAST NAME:	__________________________________________ FIRST NAME: ______________________________

SEX:	____________ 	BIRTH DATE: _______________ AGE ON RACE DAY: _______________

ADDRESS:___________________________________________________ 

CITY: 	_________________________________ STATE: ________ ZIP: _________

TELEPHONE: ___________________________  EMAIL: ____________________________________

T SHIRT:  S   M   L   XL                  ON LINE PRINTABLE APPLICATION : www.hitekracing.com
SIGNATURE: ____________________________________________
                            (parent or guradian must sign if under 18)

ENTRY FEES: 5K: $20 Pre-Reg - $25 Race Day
                            2 Mile Walk: $12 Pre-Reg - $15 Race Day
MAKE CHECK PAYABLE AND MAIL TO:
VALLEY YMCA
12 State Street
Ansonia, CT 06401

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