Name Age on 6/28/08 Sex Address Birthdate City/County/St/Zip Phone If you own your own ChampionChip, enter chip # Entrant will be competing in: 5 Mile 2 Kilometer PR :
$...............Entry Fee: $17.00 ages 17 to 59 Choice of Short Sleeve T-Shirt or $...............Entry Fee: $10.00 age 16 and under; age 60 and over Singlet if pre-registered. $...............$22.00/$14.00 for late entry after June 21, 2008. (circle selection and size) $...............Optional tax deductible donation to scholarship fund. T-Shirt: S M L XL $ ..............Alumni Scholarship Recipient tax deductible donation. Singlet: M L XL $ _______TOTAL Waiver: I hereby for myself or executors release Butler Road Race, Inc., Race Committee, City of Butler, Butler Township, County of Butler, Three Rivers Athletic Congress, Inc., USA Track & Field and all sponsors from all claims of injury, damage and courses of action whatsoever growing out of my participation in this race, and hereby certify that I am physically fit to participate in this race. If I do not own my own ChampionChip, then I hereby agree to rent a chip for this event. By signing this waiver, I become responsible to Butler Road Race, Inc, and to the Runner's High for the rental ChampionChip issued to me for this race. If I do not return this chip to the race committee on race day, I hereby agree to pay the event a replacement fee of $35. I also understand that if I do not return the chip or pay for the replacement of it, then I may be denied acceptance in any future regional race scored by Runner's High.
Signature Date Parent must also sign if runner is under 18 years:
Butler Road Race Web site: http://butlerhealthsystem.org/brr.htm mailto:butlerroadrace@butlerhealthsystem.org