Palmyra, Riverton, Cinnaminson Rotary Club's
5K Run for Life
Race Registration
Name ______________________________________________________________
Address ____________________________________________________________
City ___________________________________________
State _________ Zip Code __________________
Daytime Phone ________________ Home Phone ___________________________
Age ________ Birthdate _____________
Sex __________
eMail Address ________________________________________________________
RELEASE AND WAIVER - all entrants must sign!
In consideration for accepting this entry, and the granting
of the right to participate in this event, I the undersigned, intending to be
legally bound, hereby, for myself, my heirs, personal representatives, successors,
and assigns, waive and release any and all claims for losses and damages I may
have against Palmyra, Riverton, Cinnaminson Rotary Club, Cinnaminson Township,
Riverton Borough, Riverton Schools, Conrail, sponsors, event committee volunteers,
L&M Sports their representatives, successors and assigns/ or other person
whomsoever for any and all injuries, illness, including death, that may result
from my participation in said event. I represent and affirm that I am
in proper physical condition to participate in this event, and verified by a
licensed physician, and have sufficiently trained for the completion of this
event.
The undersign has read and voluntarily signed this release
and waiver:
_____________________________________________________________________
signature (parent or guardian's signature if under 18)
Date ___________________________________
Fee: $15 before Sept. 20 --- $20 after Sept. 20.
Make Checks payable to: PRC Rotary Charities, Inc.
Mail to: PRC Rotary 5K, PO Box 2282, Cinnaminson, NJ
08077
More Information: James Meckel, 856-802-1706. jmeckel6301@aol.com