GridleyFest Roll 'n Rolls 5K Entry Form

GridleyFest Rock `n Rolls 5K Entry Form

Make checks payable to:
GridleyFest 5-K

Send to:
Al Hany
GridleyFest 5K
PO Box 515
Gridley, IL 61744

Date/Time:
Saturday,
June 29, 2002
7:30 am

Check-in/Same Day Registration:
Starts at 6:30 am

More Information:
Al and Keri Hany
(309) 747-2130

Instructions on How to Register:
Print and complete this form. Mail it with your check to the address shown on the left.

Please complete All of the following:
Name:
Street address:
City:
State:
Zip Code:
Email:
Sex:	M F
Phone:	(###) ###-####
Date of Birth:	(mm-dd-yy)
Age on June 29:

Select one Shirt Size:
Size:	M	L	XL	XXL($1 extra)

I Wish to Enter (select one):
5K Run	5K Walk
What's your favorite running song?
Title/Artist:

Entry Fee (Non-refundable):
$12.00 by June 21	$15.00 after June 21& Race Day
Discounts:
$1.00 Lake Run Club, Starved Rock, student/athlete

I warrant that I am physically fit enough to run this race and have done proper training. In consideration of my entry, I for myself, my executors, administrators and assignees, do hereby release and discharge the GridleyFest committee, the town of Gridley, the sponsors, the Race Committee, Salem Children's Home, and/or any other individuals or groups involved with the running of this event or any or all injuries, claims and damages, demands, actions, whatever in any manner arising or growing out of my participation with the running of this event or while traveling to and from the event.


Signature (Parent if under 18)	Date