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Saturday, October 22, 2005 -- Uniontown, PA
Run for the Homeless Mainstreet Classic (iPO Event Id#: 6655)

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I am signing up for:
______5K Run/Walk as a Runner       Pre-Reg. $15           Late Reg. $18

______5K Run/Walk as a Walker       Pre-Reg. $15           Late Reg. $18  

Name_____________________________________________________________

Address___________________________________________________________

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City/State/Zip_____________________________________________________

Phone / Email______________________________________________________

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Age as of 10/22/2005                Gender

Adult Shirt Sizes:  M  L  XL  XXL            Child's Shirt Size:  S  M  L
                                              
In consideration of the acceptance of this application and intending to be legally bound, I hereby waive, discharge, and release myself and my heirs, successors, administrators, and executors, of any and all claims, damages, and causes of action of what so ever kind including negligence, that I may have as a challenge. Children, and all their respective heirs, successors, administrators, executors, asides, trustees, and parent subsidiaries or affiliated companies, if any. In addition, as an inducement for the acceptance of this application, I hereby certify that I have adequately trained for this event and am fully aware of the risks posed by motor vehicle traffic on the course. I further certify that I have read and have full understanding of its contents.

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Signature              Date


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Signature of Parent/Guardian (if under 18)           Date

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