Registration Form

Name:___________________________________________

Address:_________________________________________

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Phone:___________________________________

Email:____________________________________

Date of Birth:___________ Age on Race Day:______

Gender: Male or Female

T-shirt Size: Circle one...small...med...large...extra large

Entry Fee is $20.00 early registration by June 30th

Race Day Registration on July 3rd is $25.00

OLD FART CLUB MEMBERS RECEIVE -$5.00 DISCOUNT

club number#=________

TOTAL ENCLOSED=______________

Make checks out to: Old Farts Running Club

T-Rex Ten Miler Waiver:

WAIVER MUST BE SIGNED IN ORDER FOR ENTRY TO BE ACCEPTED...IN REGISTERING FOR THIS RACE I AM FULLY AWARE, UNDERSTAND, AND ASSUME THE RISK AND RESPONSIBILITY FOR PARTICIPATING IN THIS RACE ON A COURSE THAT IS OPEN TO VEHICULAR TRAFFIC AND HAS SOME TOUGH CHALLENGES IN IT. I HAVE FULLY CONDITIONED MYSELF TO THE APPROPIATE LEVEL OF FITNESS AND I WAIVE ALL CLAIMS AGAINST THE RACE DIRECTORS AND SPONSORS, HOST SITES AND ALL THAT ARE INVOLVED IN PUTTING ON THIS RACE, ETC., I AM ALSO AWARE OF THE FACT THAT IF THE RACE GETS CANCELLED DUE TO WEATHER OR OTHER REASONS BEYOND THE RACE SPONSORS CONTROL THAT THE RACE ENTRY FEE IS NON-REFUNDABLE.

SIGNATURE:___________________________ DATE:__________________

PARENT OR GUARDIAN IF UNDER 18 YEARS OF AGE:

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