THE RAMS RUN THE ROX 5K ENTRY FORM March 27, 2010
Please Print Clearly (Check if Applicable)
I am a Philadelphia University: STUDENT_______ FACULTY/STAFF__________ ALUMNI__________
I am a resident of Roxborough (19128 zip code)_________ (choose only 1 category if applicable)
I am participating in the ___5k Run ___ 1 Mile Walk (non competitive) Please check one
Entry Fee: 5k RUN $ 20 (up to and including 3/20/10) $25 (after 3/20/10)
$15 for all Students College age or less at all times
1 Mile Walk $15 for all (before and on race day)
Name__________________________________________ Sex________ AGE on Race Day__________
Address________________________________________________________ City____________________
State__________ Zip_______________ T Shirt Size (S-M-L-XC)______________
E Mail___________________________________________________
TEAM NAME (Team Name Must be Exactly Similar to your teamates entry form)
Team Name____________________________________________________________ (open to student, corporate, or club teams).
Teams must be made up of either ALL MALE or ALL FEMALE runners. Unlimited number of runners allowed for each team with top 3
runners scoring for the team)
Checks Made Out to : RAMS RUN THE ROX 5K
Send Check and Entry to :
Philadelphia Athletic Charities
611 Jamestown Street
Philadelphia, Pa 19128
Waiver/Release:In Consideration of accepting this entry, I the undersigned, assume the responsibility for any injury or accident which
may occur during the event or while I am on the premises of the event. I hereby release and hold harmless Philadelphia Athletic Charities,
Philadelphia University, The City of Philadelphia,the Roxborough Development Corp, and any sponsors, volunteers, or race personnel
associated with the event, whether injury occurred by negligence on the part of the sponsors or race persons. I verify that I am physically fit
and have been examined by a licensed MD. I hereby grant full permission to use any likeness from this event in the promotion of the event.
SIGNATURE (Or Parent if Under 18 years old)_______________________________________________ Date_______________
