Port Richmond 5k Race Application
May 31, 2004
Last Name _________________________________
First Name __________________________________
Race Day Age ______ Sex: ___ Male ____ Female
Port Richmond Resident: _____ Yes _____ No
Address _______________________________________
City _________________________________________
State _____ Zip Code __________ Phone _____________
Shirt Size: ___ small ___ medium ___
large ___ X-large ___ XX-large
WAIVER & RELEASE: 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 representation,
successors, and assignees, waive and release any and all claims for losses
and damages I may have against Port Richmond Race Committee, partners,
officers, directors and employees, town of Philadelphia, all sponsors,
Port ichmond community, all representatives, successors, and assignee and/or
any 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 health to participate in this event,
and verified by a licensed physican, and have sufficiently trained for
this event.
The undersigned has read and voluntarily signed this
release and waiver.
______________________________________________________ ______________
signature (parent / guardian must sign if entrant under
18) date
Make checks payable to:
- Port Richmond Run, Walk & Roll
- c/o Dr. Raymond Kent
- 2514 E. Allegheny Ave.
- Phila., PA 19134