REGISTRATION FORM

BERWYN VICTORY RUN

JUNE 11, 2005

Name ____________________________________________________________

Address __________________________________________________________

City ________________________________ State ______ Zip _______________

Age on Race Day__________ Sex _________

Daytime Phone Number_________________ Shirt Size: S ___ M ___ L____ XL ____

Please check one of the following: ___ 5K Race ___ 5K Walk ___ Kids Run

Family Name _______ Neighborhood Organization ________ Corporate Team Name ________

WAIVER AND RELEASE

For Good and valuable consideration, including REGISTRANT'S being permitted to participate in the Berwyn Victory Run, I the undersigned member ("REGISTRANT") and I the Parent or Guardian ("PARENT OR GUARDIAN")(where applicable), for myself, my successors, heirs, assigns, executors and administrators forever release and discharge Berwyn Township Committee, and any political subdivision, entity or organization on whose property any part of the Berwyn Victory Run is being conducted, and also any other sponsor and all affiliates, subsidiaries, corporate parents, officers, directors, partners, employees, servants and agents of the Berwyn Victory Run, and of any other sponsors (hereinafter individually and collectively in all combinations referred to as ("SPONSORS") from all claims, causes of action, costs and judgements that I now or hereafter may have or claim to have against SPONSORS for personal injuries, including death, damage to property, real or personal, caused by or arising out of REGISTRANT'S involvement in any Berwyn Victory Run Event. I further agree to and do hereby assume any and all risks of personal injuries to REGISTRANT, including death, and damages to REGISTRANT'S property, real or personal, caused by or arising out of REGISTRANT'S involvement in any Berwyn Victory Run Event. I further agree for myself, my successors, heirs, executors and administrators to indemnify and hold SPONSORS harmless from all claims and suits for personal injuries, including death, and damages to property, real and personal, in any way arising out of REGISTRANT'S involvement in any Berwyn Victory Run Event, and from all judgements and costs recovered in said claims and suits and from all expenses incurred in defending said claims or suits. I further understand and agree that the involvement of commercial SPONSORS in any Berwyn Victory Run Event is for purely advertising purposes only and that they have no involvement in the course set-up or the running or safety features of the race. I warrant the REGISTRANT is in good health and has no physical condition that would prevent REGISTRANT from competing in any Berwyn Victory Run Event.

____________________________________________________________ ________________________________________________________

Signature of Adult or Parent if racer is under 18                                                    Date