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Saturday, October 11, 2003 -- Greensburg, PA
Centurion Fall 5K (iPO Event Id#: 5786)

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Name_________________________________________________________

Address______________________________________________________

Phone________________  Birthdate____________      Run    Walk

Shirt Size:  Small    Medium    Large    X-Large

Amount Enclosed:________ Checks payable to: GCC Cross Country

Mail to:  Renee Fagan
17 Spring Run Road, Greensburg, PA  15601
In consideration of the acceptance of this entry, I waive myself, my heirs, and assigns, all claims for damages which I might have against the race, its sponsors, or any organization Business or individual as a result of any and all injuries which might be received during the contest. I attest that I have sufficiently trained for this event. I also release any photos that may involve myself.

Signature____________________________________________
(parent must sign for minor)