3rd Annual Jack Saint Clair Memorial Cross Country Championship Entry Form Sat,Oct 2 2010
Print Name_____________________________________________
Sex:____________ Which Race (circle one) Men /5 Mile Women 6,000 Meter
Age on Race Day____________ Mid Atlantic USATF 2010 Member (Yes/No)________ #___________________
Address____________________________________________________________
City______________________________ State___________ Zip_________________
E Mail:__________________________________________________ T Shirt Size :___________
Registration Fee: $15 (on or before Sept 23, 2010) $20 (after Sept 23,2010)
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, 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__________________________