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You can use this form to:

FAX: 301.934.0384 (print the form, fill out the info and fax it)
MAIL: Civista Health Foundation • PO Box 1701 • La Plata, MD 20646 (print the form and mail it)
EMAIL: [email protected] (copy and paste the text below into your email message)

Run Walk Registration Information...........................................................................................

Name:

Phone:

Address:

City:

State:

Zipcode:

Date of Birth __ __/__ __/__ __

My Best Run Time:

___Male  ___Female    T-shirt size:   ___2X    ___XL    ___L    ___M    ___Child's Large

Entry for ___Run  ___Walk ___Wheelchair

Do Not Email Credit Card Info! ..............................................................................................................

Visa, Mastercard, Discover (circle one) Please Do Not email credit card information.This site is not encrypted and information can be electronically intercepted.

Cardholder Name as Appears on Card: ...................................................................................................................

Amount Total: $....................................................... ($20 per entry, $15 if received by April 18)

Account Number: ..... ..... ..... ..... -..... ..... ..... .....-..... ..... ..... ..... -..... ..... ..... ..... Expiration Date: .......................

Cardholder Signature: ...........................................................................................

Waiver............................................................................................................................................................

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 also know that although police protection will be provided, there will be traffic on the course route. I assume the risk of running in traffic. I also assume any and all other risks associated with running this event including but not limited to falls, contact with other participants, the affects of the weather, including high heat and/or humidity, and the condition of the roads, all such risks being known and appreciated to me. Knowing these facts, and in consideration of my entry acceptance, I hereby for myself, my heirs, executors, administrators, or anyone else who might claim on my behalf covenant not to sue, and waive, release and discharge Civista Health Foundation, including the Police Department, Emergency Radio Systems, Race Officials, Volunteers, any and all sponsors including their agents, employees, assigns, or anyone acting for or on their behalf, from any and all claims of liability for death, personal injury or property damage of any kind or nature whatsoever arising out of, or in the course of my participation of this event. The Release and Waiver extends all claims of every kind of nature whatsoever, foreseen and unforeseen, known or unknown. The undersigned further grants full permission to Civista Health Foundation and or agents authorized by to use any photographs, videotapes, motion pictures, recordings, or any other records of this event for any purpose.

My signature is my understanding of the waiver: ........................................................................................................................

Date: ..............................................................................                        

Applications for minors will only be accepted with parental signature: .............................................................................................

Date: ..............................................................................

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