IRISH TROT
SATURDAY, MARCH 17, 2012 8:00 A.M.
| IRISH TROT | REGISTRATION FORM |
| FUN | |
| 5K RUN/WALK | NAME______________________________________________ |
| ADDRESS___________________________________________ | |
| ENTRY FEES | CITY__________________________ ST______ ZIP_________ |
| $15 for entries received by March 9, 2012 | |
| (Fee includes t-shirt) | |
| T-SHIRT SIZE (CIRCLE ONE): S M L XL XXL | |
| $15 for entries received March 9, 2012 or after | |
| WAIVER AND RELEASE | |
| PRIZES | I hereby for myself, and/or my minor child (if applicable), and the |
| $50 prize will be awarded to the top | administrators, heirs, and assigns thereof waive and release any and all |
| male and female finishers | rights and claims for damages and personal injuries , resulting from |
| negligence, which I or my child may have against; St. Patrick's Celebration, | |
| All participants in the 5K will be entered | its officers, directors, employees, and volunteers; the organizers of the |
| into a drawing for prizes | St. Patrick's Celebration Irish Trot 5K Run/Walk; their sponsors, associates, |
| contractors, other entrants and representatives; Dubois County, its boards, | |
| elected and appointed officials, and its employees, all for property damage | |
| CHECKS FOR ENTRY FEE MADE PAYABLE TO: | or personal injury, including death that may arise or grow out of my or |
| St. Patrick's Celebration | my minor child's participation in the St. Patrick's Celebration Irish Trot. |
| I certify that I and/or my child have prepared for this event. I agree to | |
| follow the rules of this race, obey all traffic laws, avoid littering, and | |
| ENTRIES MAY BE MAILED TO: | respect the property of others. |
| Tara Sendelweck | |
| 4278 W 300 N | ______________________________________________________ |
| Jasper, IN 47546 | SIGNATURE OF PARTICIPANT |
| If questions, call 482-2143 | ______________________________________________________ |
| SIGNATURE OF PARENT/GUARDIAN IF PARTICIPANT IS UNDER 18 | |
| _______________________ | |
| All proceeds are donated to Ireland Community Projects | DATE |
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