Name:

Address:

City State Zip

Birth date:  Mo Day Year

Age on race day:   Sex: Male   Female

Daytime phone:  

T-shirt size: S   M    L    XL

Which race? 5K   Fun run

If participating with a team, provide corporate or school name:

Fees:
5K Adults/Youth—$15 ($20 after 10/6/08)
Fun Run—$5 ($10 after 10/6/08)
Family—$25 ($30 after 10/6/08)

Make checks payable to North Penn United Way
All fees are tax-deductible contributions to the United Way.

List additional runners in your family below:

Name:

Birth date:  Mo Day Year

Age on race day:   Sex: Male   Female

T-shirt size: S   M    L    XL

Which race? 5K   Fun run

Name:

Birth date:  Mo Day Year

Age on race day:   Sex: Male   Female

T-shirt size: S   M    L    XL

Which race? 5K   Fun run

Name:

Birth date:  Mo Day Year

Age on race day:   Sex: Male   Female

T-shirt size: S   M    L    XL

Which race? 5K   Fun run

Name:

Birth date:  Mo Day Year

Age on race day:   Sex: Male   Female

T-shirt size: S   M    L    XL

Which race? 5K   Fun run

Acknowledgement, waiver and release from liability

I acknowledge that running is an extreme test of a person's physical and mental limits and comes with the potential for death, serious injury, and property loss. I HEREBY ASSUME THE RISK OF PARTICIPATING IN RUNNING EVENTS. I certify that I am physically fit, have sufficiently trained for participation in this event, and have not been advised otherwise by a qualified medical person. 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 RISK WITH RUNNING THIS EVENT, including but not limited to, falls, contact with other participants, the effects of the weather, including high heat and/or humidity, and the condition of the roads, all such risks being known and appreciated by me.

In consideration for allowing me to participate in this event, I hereby take the following action for myself, my executors, administrators, heirs, next of kin and successors, and aver (a) WAIVE, RELEASE AND DISCHARGE from any and all claims or liabilities for death, personal injury, property damage or damages of any kind that arise out of or relate to my participation in, or my traveling to and from the North Penn United Way "Run for Your Neighbor" 5K Road Race and Family Fun Run, THE FOLLOWING PERSONS OR ENTITIES: North Penn United Way, Harleysville Mutual Insurance Company and all of its subsidiary and affiliated companies, and its and their respective directors and officers, agents, servants and employees, and all event sponsors, race directors, event producers, volunteers, and (b) AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities I have waived, released and discharged.

The undersigned further grants full permission to the parties listed above and/or agents authorized by them, to use any photographs, video tapes, motion pictures, recording or other record of this event for any purpose. Applications for minors will be accepted only with a parent's signature.

Printed name:

Date:

Signature (written): 

Parent's signature for participant under age 18

Parent's printed name:

Parent's signature (written):