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Please Print
Name: __________________________________________________
Last Name
First Name
Address: ________________________________________________
City:
_____________________________State: ____ Zip: _________
_
Phone:________________Email:
____________________________
Age on Race Day: _______
Gender (circle one): M F
T-Shirt Size (Please circle one)
S M
L XL
Entry Fee:
Early Registration Thru February 29,
2012......... $ 15.00 ______
After February 29,
2012......................................... $ 20.00 ______
Morning of
Event.................................................... $ 25.00
______
Extra T-Shirt if
available....................................... $
8.00 ______
Total..........................................................................
$ _________
Please read the waiver and sign the form (MANDATORY) Thank You.
Waiver: 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 damages I may
have against Advanced Independence LLC, All Arizona Running Events,
City of Peoria, or anyone associated with this event, their
representatives, successors, and assigns, for any and all injuries
suffered by me in said event. I will additionally permit the
free use of my name and pictures in broadcasts, telecasts,
newspapers, etc.
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