35th ANNUAL
5 MILE RUN & 2K RUN / HEALTH WALK
SATURDAY  JUNE 26, 2010

 
   
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Fill in the blanks and print your entry (click printer icon) or print a blank entry and make extra copies.

Cut along lines and send to: Runner's High,  479 Mercer-New Wilmington Rd.,  Mercer, PA  16137
Make checks payable to: Butler Road Race Inc.

 

       2010 ENTRY FORM

 Name Age on 6/26/10 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: $18.00 ages 17 to 59                                            
 $...............Entry Fee: $10.00 age 16 and under; age 60 and over              Guaranteed T-Shirt if pre-registered.
 $...............$23.00/$15.00 for late entry after June 12, 2010.                         (circle size)
 $...............Optional tax deductible donation to scholarship fund.           T-Shirt:       S    M    L    XL   XXL
 $ ..............Alumni Scholarship Recipient tax deductible donation.  
 $ _______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/brrhome.htm