Name ________________________________________________________

Age on Race Day __________      Sex ______________

Address _______________________________________________________

City ________________________________   State _____  Zip Code ___________

Daytime Phone Number _____________________

Please check one of the following    _____ 5K Race    ____ Fun Walk

If applicable, choose one:

_____  Bancroft Individual Served   _____  Bancroft Staff    ______  Haddonfield Resident

Team Challenge Categories:

Corporate Team: _____________________________________________

School Team: ________________________________________________

Police/Fire/EMS Team: _________________________________________________

*Please submit team entries collectively by March 12, 2005
.

Make checks payable to: BANCROFT NEUROHEALTH

Mail checks and entry form to:
Bancroft NeuroHealth
425 Kings Highway East, P.O. Box 20
Haddonfield, NJ 08033-0018

To charge, please complete:

Visa ___     MC ____      AMEX ____       Exp. Date: ______

Card # ____________________________

Release: I, the undersigned, acknowledge that a road race is a potentially hazardous activity. I certify that I am medically able and have sufficiently trained for this event. I agree to abide by all decisions of the race as final. In consideration of the accetance of my entry and intending to be legally bound, I do hereby for myself, and anyone entitled to act on my behalf, waive, release, and discharge Bancroft NeuroHealth, its officers, staff members, and the borough of Haddonfield and all other sponsors and participants from any and all liabilities arising out of my participation in this event.
Signuature or Parental Signature if under 18:
______________________________________________________________

Sponsorship Form (Please submit by March 5, 2005)