| Philadelphia Catholic League XC Open Championship 2011 Saturday, October 22, 2011 1pm Start Belmont Plateau $15 (by Oct 15th) $20 (after Oct 15th) Check to Philadelphia Athletic Charities and Send to 611 Jamestown St, Phila , Pa , 19128 Please print Name__________________________________________ Address_________________________________________________ City____________________ State________ Zip_______________ Sex___________ Age on Race Day________ I am a graduate of a Philadelphia Catholic League School*_______(y/n) PCL School and year graduated_______________________________________ Are you a Mid Atlantic USATF member for 2011______________(yes or no) If yes, list your USATF #__________________________ (needed for scoring for the USATF XC Series) * race is open to all runners (PCL info only needed for eligibility of Phila. Catholic League team championship) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Disclamer, Waiver, and Release: In consideration of accepting this entry, I the undersigned, assume full 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 Inc, Phila Catholic League Coaches Assoc, City of Philadelphia, and all sponsors, volunteers and other associations connected with the event whether injury or death is caused by negligence on the part of race persons. I verify that I am physically fit enough to participate in this event and my health is verified by a licensed MD. I hereby grant permission to the event management to use my likeness in print, or photo for any future promotion. ______________________________________________ ____________________ Signature of runner or parent if under 18 years old Date |
