Wieder Memorial Run Registration

1
Print and fill out this form agreeing with the waiver by your signature.

Please enter me in the Wieder Memorial Run on June 4, 2005, in consideration of this entry being accepted. I hereby for myself, heirs, executors, administrators, and any minor child (if applicable) waive and release any and all rights of claims for damages I may have against the Upper Bucks YMCA, Quakertown Borough, Richland Township, Quakertown Community School District, Allentown District Office of Colliers and Lanard, all sponsors, and all other persons associated with this event, its agents, representatives, and successors. It is my further declaration that I consider myself to be in excellent physical health and that I have sufficient training so as to be in such physical condition that will enable me to participate in and complete the race. I assume all risks associated with running in this event including, but not limited to, falls, contact with other participants, the effects of the weather, including high heat or humidity, traffic conditions of the road, and such risks being known and appreciated by me. I have read and show my understanding of this waiver by signing below.

PLEASE PRINT CLEARLY - Make Checks Payable to: Quakertown Community School District

Name_________________________________ Age______

Address__________________________________

City________________________ State______ Zip____________

Phone (_______)________________ Email____________________

Signature_________________________________

Parent Signature (If Under 18)_________________________________

Check the lines that apply: Male____ Female____ 5k____ 1-Mile Fun-Run/Walk____

Circle your shirt size: S ------ M ------ L ------ XL Today’s Date_____/______/______

2
Check Entry Fees below to assure the amount you must pay to enter either race.

Entry Fees
*All pre-registered participants receive a t-shirt
*All proceeds contribute to the Mark and Rae Ann Wieder Scholarship Fund
*All fees are the same for both the 5k and the 1-Mile Fun-Run/Walk

Amount enclosed: $_________

3
Mail the completed form (with the waiver attached) and your entry fee to:
Wieder Memorial Run
Quakertown High School
600 Park Ave.
Quakertown, PA 18951