Entry Form

Release:
I know that running a road race is a potentially hazardous activity, I should not enter and run unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running in this event, including, but not limited to, falls, contact with other participants, the effects of the weather, including high heat and/or humidity, traffic and the conditions of the road, all such risks being known and appreciated by me. Having read this waive and knowing the facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf waive and release the Tioghnioga Fire Department, Town of DeRuyter, Village of DeRuyter, DeRuyter Central School, Town of Cuyler, Cortland County, Madison County, Onondaga County, Town of Cazenovia, Town of Fabius, race organizers, and all sponsors, their representatives and successors from all claims of liabilities of any kind arising out of my participating in this event. I also understand that in the event these races cannot be held as scheduled because of an act of God or circumstances beyound control, the race is not liable to refund entry fees.

Signature of runner_____________________________________    Age on run day________

Date of Birth____________Signature of parents if under 18________________________

Print Full Name__________________________________ Male___ Female___

Address______________________________ City__________________________ State_______

Zip_________ Phone(____)_____________

Entry fee: $15.00 ($25 maximum per family)     Fun Run $1.00

After August 3rd, the fee is $20.00 (family maximum $35)

I will be running in the (CIRCLE ONE)      FUN RUN      5 KM Run      Half-Marathon

Optional T-Shirt add $12     CIRCLE SIZE:    medium      large      extra large      Optional Patch add $5 CIRCLE    yes

Family combinations: If entering, add 25 cents, (50 cents per team) to the entry fee.

State which combination ____________and name of team member.______________________

Total fees$___________ Please make checks payable to:TIOUGHNIOGA FIRE DEPARTMENT. Please only ONE person per entry form.

Print and complete this form and mail with a check or moneyorder to:

Win Skeele, Box 351, DeRuyter, NY 13052

______________________________________________________________________________________________________

Official use only: Entry___________________Shirt__________________Patch________________Team_________________