Registration Form for Zack's Run 5K & 1M Fun Run
College Park, University of Maryland - 8:00 am
Sunday, September 23, 2001

Make check payable to: The Zachary Hebda Foundation
Mail to: Zack's Run, 13710 Ashby Road, Rockville, MD 20853-2903   Fax to: (301) 871-0006
Do not mail after September 17, or fax after September 19

Today's Date: , 2001
Event: 5K   1 Mile Fun Run                 
Entry Fee 5K:  $17   $20 if postmarked after September 10 and race day
Entry Fee 1 Mile Fun Run   $10
I am on a team (5 persons only)      Team name   
All team entry forms need to be sent together
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  XXL  
Day Phone: - - Night Phone: - -

Credit Card: MC Visa - - - Exp:
Cardholder's Signature (Mandatory) __________________________________________

Waiver/Release Must be Signed Before Mailing:

In consideration of the application being accepted, I hereby, for myself, my heirs, and executors waive, release and forever, discharge any and all rights and claims to damages which I may have hereafter accrue to me against the organizers and sponsors of the Zack's Run, The Zachary Hebda Foundation, The University of Maryland, University of Maryland Police Department, Capital Running Company, USATF, or other sponsors and their representatives, successors, and assigns, and verify that I am physically fit and have sufficiently trained for the competition of this race.   Further, I hereby grant full permission to any and all of the foregoing to use my name, photograph, videotapes, motion pictures, recordings, or any other record of this event for any legitimate purpose, without compensation or remuneration. Race Management and Finish Line Services by Capital Running Company.


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

washrunreport.gif (4240 bytes)