38th ANNUAL

CAPTAIN BILL GALLAGHER ISLAND RUN

OFFICIAL ENTRY FORM

First Name ____________________________ Last Name ____________________________

Street Address ______________________________________________________________

City ________________________________ State ______   Zip Code___________      

Sex       M       F     (circle one)            Age on Race Day _________     

Phone (_____) ______ ____________         T-shirt   S   M   L    XL (circle one)

    _____ Beach Patrol Team    ____ Running Club Team    _____  Corporate Team   

                      _____ Police Officer   ____ Firefighter   ____ SICBP Alumni    (check one only)

Team Name / Affiliation ___________________________________________________________

If you wish our medical staff to be aware of any specific medical problems or medications, please explain.

_______________________________________________________________________________

Mail entry forms to                                     or              Deliver entry forms to:       

Sea Isle City Beach Patrol                                          Beach Patrol Headquater's   
4416 Landis Ave.                                                         44th Street & Boardwalk
Sea Isle City, NJ   08243                                             (609) 263-3655 
                                                                                   number operating after June 15th
                                                                                                                                                                                              RELEASE FORM (Mandatory)
I understand that I am financially responsible for any and all medical bills incurred by myself or my child while participating in this running race. In case of emergency, I grant permission for myself or my child to be given emergency treatment by the appropriate medical personnel.  In consideration of accepting this entry, I, the undersigned, intending to be legally bound, hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for losses, and damages I may have against the Sea Isle City Beach Patrol, Sea Isle City, and all other parties and their representatives, successors and assigns for any and all injuries suffered by me in said event. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event, and my physical condition has been verified by a licensed medical doctor. Further, I hereby grant full permission to any and all foregoing to use photographs, videotapes, motion pictures, recordings and any other records of this event for any purpose whatsoever. NO ONE MAY ENTER THIS EVENT WITHOUT SIGNING THIS OFFICIAL WAIVER !

signature _________________________________________________________    date __________________

Parent/guardian's signature if under 18 years of age __________________________________ date ___________