Wings Over Loudoun 10K & 1M Fun Run
Sunday, October 28, 2001  9:00 AM (Fun Run: 9:10)

Make check payable to: LCDS PA (Loudoun Country Day School Parents' Association)
Mail to: Wings Over Loudoun 10K, 13710 Ashby Road, Rockville, MD 20853-2903
Fax to: (301) 871-0006 before October 24       Do Not Mail After October 22

Today's Date: , 2001        Event: 10K   1 Mile Fun Run   
Entry Fee 10K: $15   $18 after October 15  $20 on raceday
Fun Run $15
I want to volunteer
I am a ChampionChip owner and am deducting $2.  My Chip number is  
I want to buy my own ChampionChip.  I am enclosing $35 payable to Capital Running Co.

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

Credit Card: MC VisaAmex - - - 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 inconsideration of your accepting my entry, I, for myself, and anyone else acting on my benefit, waive and release the organizers of the Wings Over Loudoun 10K and Fun Run, Loudoun Country Day School Parents Association (LCDS PA),  Capital Running Company, USATF, and all other sponsors, their representatives and successors 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. Further, I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for legitimate purposes.

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