Sunday, April 10, 2011 -- Hopwood, PA / Route 40
Mount Summit Challenge ENTRY FORM
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RACE CONTACT: Joe Thomas (phone) 724-438-0628 in the evening, (e-mail) officers@fayettestriders.org
Entry Fee:
- $20 (by March 20) . . . $25 (after March 20)
- $5 off if participant is 18 years of age or younger
- Add Additional $2 for XXL shirt
- Additional party tickets for non-racers are $3 per ticket
Registration includes one party ticket! Shirts are not guaranteed after March 20th registration.
Cash/cashier's check preferred on race day. $25.00 charge for all returned checks.
Payable / Mail to: Fayette Striders Running Club, P.O. Box 1441, Uniontown, PA 15401
Please PRINT CLEARLY (Incomplete applications will NOT be processed!)
Name_____________________________________________________________________________
Age _______ Date of Birth ______/_________/______________ Sex: Female___ Male ___
Address__________________________________________________________________________
City______________________________________________ State______ Zip_______________
Phone (_____________)_____________________________
E-mail __________________________________________________________________________
Check One Event: Open/Age Group____ Cruiser____ Clydesdale____ Walker____
Shirt Size: S____ M____ L____ XL____ XXL(+$2.00)____
Number of Additional Party Tickets (non-racers): ______ $3.00 per ticket
In consideration of my entry being accepted in the Mt. Summit Challenge race, I, intending to be legally bound, do hereby, for myself, my heirs, executors, and assigns, waiver, release and forever discharge any and all rights and claims for damages that I may have or which may hereafter accrue to me against the Mt. Summit Challenge, Fayette Striders Running Club, SERJ Racing Services, PennDOT and all sponsors. I understand the difficulty of this event and agree that I am in good physical condition.
_______________________________________________________________________________
Athlete Signature
___________________________________
Date
_______________________________________________________________________________
Signature of Parent/ Guardian if Athlete is under 18 yrs of age