Drumstick Dash
-
November 22, 2007
Web Entry Form
I plan to do: r
4.5 Mile Course r
2.6 Mile Fun Run Course (no chip timing)
First name_______________________ Last
name____________________________________
Address______________________________________________________________________
City______________________________________ State______________
ZIP____________________
Phone - day _________________________ Phone - evening
__________________________
E-mail address
________________________________________________________________
Sex: r Male r
Female Age:_____________
T-Shirt size q S q M q L q XL
q XXL
Payment: q
$20.00 Long Sleeve Shirt entered
by Nov 18 q $25.00
Long Sleeve shirt (entered after 11/18)
- note: shirt and shirt size is not guaranteed on race day.
Note: After the first two - each family member is only $15.00
-or $10 for ages 12 and under
q
I would like to donate an extra
$______ to benefit the Wheeler Mission Ministries
Credit Card r
Visa r
Master Card
Card # _____________________________________________ Exp. Date ________
Signature below will validate charge card. Total amount to be
charged $______
FAX TO: 317-873-5803 - deadline for fax is Monday at 5 pm on November 19.
WAIVER (Must be signed)
In consideration of the foregoing,
I, for myself, my heirs, executors and administrators, waive and release any and
all rights and claims for damages I may have against any of the sponsors,
organizers, City of Indianapolis, Wheeler Mission Ministries,
The Running Company, Tuxedo Brothers, Inc., Broad
Ripple High School, their employees, contractors, volunteers for any
and all claims of damages, demands or loss actions whatsoever which may arise as a result
of my participation in this 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. I also understand the unique nature of this running
event. Further, I grant full permission to any and all of the foregoing to use my likeness
for any legitimate purpose whatsoever
______________________________________________________________________