April 30, 2005

Name:            ______________________    ______________________    Age:    ______

                        (First name)                         (Last name)

Address:        ____________________________________________

                      ____________________________________________

 

Adult t-shirt size:                _____ 2XL  _____ XL _____ Lg _____ Med _____ Small

(Check appropriate size)    _____ None

Club South Runners member:     Yes      No

Waiver

I do hereby release Club South Runners, The City of Denham Springs, The Greater Denham Springs Chamber of Commerce, Main Street of Denham Springs, race director and officials, volunteers, sponsors and their representatives, successors and assigns for any and all injuries suffered by me in said event however incurred or sustained.  I know that running a road race is a potentially hazardous activity.  I attest and verify that I am physically fit and sufficiently trained for the completion of this event.  I assume all risks associated with running in this event including but no limited to falls, contact with any participants, and the effect of the weather including high heat and humidity, traffic and the conditions of the course.  Further, I hereby grant full permission to any and all of the foregoing, as well as recognized news media, to use any photograph, videotape, motion picture recording or any other record of this event for any purpose whatsoever.  I agree to abide by any decision of the race director, race officials and medical personnel relative to my ability to safely complete the run, as well as the safety of other participants.  I attest that with my signature provided below that I am 18 years of age or older or that in addition to my signature I have provided the signature of my legal parent or guardian. 

Date:    __________       Signature:        __________________________________________

                                                            (Signature of runner/participant or parent or guardian if under 18)

Pre-registration (by April 20):

$12 for Club South members

$15 for  non members

Race day registration:

$18 per person

$10 per person no T-shirt

 

Make checks payable to:                                                      

The Greater Denham Springs Chamber of Commerce                                Karen Lively,

991 Government Street                                                                             Executive Director

Denham Springs, LA  70726                                                                    225-665-8155