ENTRY FORM AND RELEASE

Stephanie Burke 5K Run and 1 Mile Fun/Run Walk

Saturday, June 21, 2008

All participants Must Complete and sign this form.

Make checks payable to: South Jersey Cancer Fund

Send check & Entry Forms to:

Beach Run 2008; 209 Lincoln Dr; Brigantine, NJ 08203

For more information please contact:(609) 266-5186 or email DanaMikeG@aol.com

Name _____________________________________________

Street Address __________________________________________

City _______________________________ State ____ Zip Code _________

Phone ______________________________

Email ______________________________

Age ______ Sex ____ Shirt Size S__ M__ L__ XL___

5K Run _____ 1 Mile Fun Walk ____

Race fee: $ ___________

Relase and Wavier ( All Entrants must sign )

I understand that my consent to these provisions is given in consideration for being permitted to participate in this event. I am a voluntary participant in this event, and in good physical condition. I hereby release and hold harmless South Jersey Cancer Fund, City of Brigantine, LMSports and any affiliated individuals from any claims I may have from my participation in this event, including personal injury. If I do not follow the rules to this event, I understand that I may be removed from the competition.

_______________________________________________________________ Signature ____________Date

_______________________________________________________ Parents Signature(under 19) ___________Date