Name:_________________________________________________________________________ Sex: M   F

Address:_______________________________________________________________________

Age on race day:______ Phone Number:______________________Shirt size (circle one): M    L   XL

Running/walking in memory of:____________________________________________________

In consideration fob the acceptance of my entry, and intending to be legally bound, I hereby, for myself, my heirs, my executors, and administrators, do waive, release, and discharge all rights and claims which I may have, or which may hereafter accrue to me, against The Pennsylvania State University, its officers, agents, and employees of, and all named and unnamed sponsors and volunteers and from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident suffered by me (or the said minor) while traveling to and from the event, participating in the event, or using any and all facilities. I understand that any race is potentially dangerous, and hereby attest and affirm that I am sufficiently conditioned for the event.

Signature of entrant:_____________________________________________________ Date:______________________

Signature of parent/guardian:______________________________________________ Date:______________________
(if entrant is under 18 years of age)