Tenth Annual Van Metre 5 Mile Run
Saturday, October 6, 2001  8:30 AM

Make check payable to: Van Metre 5 Mile Run
Mail to: Van Metre 5 Mile Run, 13710 Ashby Road, Rockville, MD 20853-2903
Fax to: (301) 871-0006 before October 3                         Mail before October 1

Today's Date: , 2001
Event:5 Mile Run  1 Mile Fun Run  1 Mile Walk
Entry Fee: $15  $20 if postmarked after Sept 28 and raceday
Children 12 and under $5      Corporate team $50 plus $15 per member  Team Name: ______________________
Additional contribution to Children's Hospital  $ ______   Broadlands resident ? Yes  No

Last Name:
Address:
City: State: Zip: -
Age on race day: Sex: M F         E-Mail:
Date of Birth: / / Shirt Size:  M L XL      
Day Phone: - - Night Phone: - -

Credit Card: MC  Visa   ---  Exp:  

Cardholder's Signature (Mandatory) __________________________________________

Waiver/Release Must be Signed Before Mailing:

I know that running is a potentially hazardous activity and I should not enter unless I am medically able and properly trained. I assume all risks associated with running in this event including, but not limited to, falls, contact with other participants, the effects of weather and the conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing the facts and in consideration of your accepting my entry, I, for myself, and anyone else acting on my benefit waive and release and indemnify the Van Metre 5 Mile Run, Capital Running Company, plus all sponsors, their representatives and assignors from all claims or liabilities of any kind arising out of my participation in this event, even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. Race management and finish line services provided by Capital Running Company.

_________________________________________________________ __________
Signature (parent or guardian if under 18)                                                          Date