Emily's Run and Walk - September 26, 2004
Web Entry Form
q 5 Mile Run  q 3 Mile Fun Walk
Name:___________________________________  Age on 9-26-04:______q Male   qFemale
Street:_______________________________________________________________________
City:________________________________________State:_____________ Zip:___________
Day Phone:_________________________ Evening Phone:___________________________

T-Shirt size: r S r M r L r  XL
Fees:
Pre-registered for the 5 Mile Run - $20
Pre-registered for the Family Fun Walk - $20 per person or $50 per family (please send all in together)
CHECKS ARE PAYABLE TO: Emily Hunt Foundation

Mail completed entry form and entry fee to: 
Tuxedo Brothers, 6265 Boone Ridge, Zionsville, IN 46077
RACE PARTICIPATION AGREEMENT: 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, Tuxedo Brothers, Inc., 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 understand and acknowledge that participating in this run/walk event may expose me to dangers from both known and anticipated risks. 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 grant full permission to any and all of the foregoing to use my likeness for any legitimate purpose whatsoever.

Signature_______________________________________________ Date __________________
Parent’s or Guardian’s Signature if under age 18_______________________________ Date ______________
Incomplete/unsigned entries will not be accepted. - Entry form can be copied.
Must be post marked no later than September 9-21-04