4th Annual  Jack Saint Clair Memorial Cross Country Championship Entry Form       Sat,Oct 8 2011
  * This Entry Form is for Open Runners Only.  All College and Open Club teams must register by
      having their head coach contact Coach Dave Thomas (thomasd611@ yahoo.com)
for team list.
     (Team list - include name, age, gender of each team member)


Print Name_____________________________________________  

Sex:____________           Which Race (circle one)      
             Men /5 Mile         Women 6,000 Meter

Age on Race Day____________       Mid Atlantic USATF 2011 Member (Yes/No)________  #___________________

Address____________________________________________________________

City______________________________   State___________    Zip_________________

E Mail:__________________________________________________   T Shirt Size :___________

If you are a 2012 Mid Atlantic USATF member, list your #__________________________ (needed to be included for
scoring for the 2011 USATF XC Series).  


Registration Fee:   $15 (on or before Oct1, 2011)        $20 (after Oct 1,2011)
  Make Checks Payable and Send to:
   
 Philadelphia Athletic Charities       611 Jamestown Street    Philadelphia  Pa   19128

Waiver and Release: I know that running a cross country race is a potentially hazardous activity. I should not enter and run unless I am medically able and
properly trained for this race. I assume all risks associated with running the race at Belmont Plateau, including, but not limited to falls,contact with other
runners, the effects of weather and all such risks being known to me. Having read this waiver and knowing these facts, and in consideration of our accepting my
entry to participate in the Jack Saint Clair Memorial, I, for myself and anyone entitled to act on my behalf, waive and release Philadelphia Athletic Charities,
Fast Cat Sports Productions,LLC, the City of Philadelphia,Philadelphia University,  and any family, volunteers, sponsors or volunteers or their representatives
form all claims or liabilities of any kind arising out of my participation in the race.   I also release my image to be used for any promotion to be used from this
race event.

Signature:___________________________________________ (or Gaurdian)      Date__________________________