Garnet and Gold 5K Charity Run - Registration Form
03/26/09
To fill out the registration form, select below the dotted line, copy the registration text, paste it into Word or Notepad and print it out.
Alternatively, you can go to the following link for a PDF version of the form: http://www.mediafire.com/?sharekey=c4bdfcfdc12c1fb3bda4076e811714c8e04e75f6e8ebb871
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Saturday, April 11, 2009, 9:30 – 10:45a.m. Registration, 11:00 a.m. Start
Veterans Memorial Park, Middletown, CT
Proceeds will be going to the Eddy Shelter in Middletown, CT
Make checks payable to “Xi Chapter of Psi Upsilon” Mail to:
Xi Chapter of Psi Upsilon Attn: Charity Race, PO Box 2458 Middletown, CT 06457
Registration Fee - $15 the day of the event, $10 if postmarked by 4/5/08. All fees are non-refundable.
Please Print:
Last Name________________________ First Name _______________________
Address __________________________________________________________
City ___________________________ State ____________________ Zip_______________
Phone _____________ Age (on race day) _______ Birth date __________
Sex: Male ___ Female___
Cost of T-shirt is an extra $5 and must be ordered before 3/25/08 to be guaranteed to get one.
T-shirt size: M__ L__XL__
Donation: Registration ($10) ___ + T-shirt ($5) ___ + Extra Donation (Optional) ___
Total Amount: _____________
Waiver: In consideration for my participation in the Garnet and Gold Charity Run 2009 I personally assume all risks, whether foreseen or unforeseen, in connection with the Event, of any harm, injury or damage that may befall me as a participant. I release and hold harmless the Xi Chapter of Psi Upsilon, City of Middletown, and any organizers and/or sponsors of the Event (collectively referred to as "Released Parties") from any claim or lawsuit for personal injury, property damage or wrongful death, by me, my family, estate, heirs or assigns, arising out of participation in the Event, including both claims arising during the activity and after I complete the activity and including claims based on negligence of other participants or the Released Parties, whether active or passive. I represent that no known physical or health limitations prevent me from safely participating in this Event. I agree to allow my image to be used in any and all published materials and websites that promote the event. Application for minors under 18 will be accepted only with parent's signature.
Signature of Participant: __________________________________________________
Signature of Parent/Guardian: ______________________________________________
(required if participant is under 18 years of age)
