Dick Lugar Community Run & Walk -
September 15, 2007
Web Entry Form
Check event:
r5K Fitness Walk
r5K Racewalk
r5K Run
r10K Run
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 $18.00 no shirt q
$22.00 Short Sleeve Shirt
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, Senator Richard Lugar, U.S. Senate, Butler University, Tuxedo Brothers, Inc., 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
______________________________________________________________________