A Rosary High School Alumnae Sponsored Event Road Scholar 5k Run/Walk Official Entry Form * One Form Per Person
Name:
Address:
City:
State: Zip:
Phone:
Home- Work-
BirthDate:
Age at time of race:
Email:
Please check one in each category:
Sex:
Male Female
T-Shirt:
XXL XL L M S
Rosary Alumna Class of _________
I am:
Individual Participant $20.00 ($25 on race day)
Rosary/Marmion Student $5.00 ($10 on race day)
Family Members (up to 4 family members of the same household) $50.00 per family (Not available on race day)
I would like to make a donation of $
In case of an emergency, please fill in the information below:
Emergency Contact Name:
Emergency Contact Number:
Waiver: Please enter me in the Road Scholar 5K Run/Walk. To induce Rosary High School to accept my entry and permit me to participate in the race and in consideration thereof: 1) I do hereby represent that I understand that participation in this run/walk is physically strenuous and that I am physically fit to compete; 2) I hereby for myself, my heirs, executors, administrators and assistants waive and release any and all rights and claim for damages which I may have against Rosary High School, the City of Aurora, their representatives, successors, agents, employees, assigns, volunteer workers, and any sponsoring organizations for any and all injuries; and/or damages I may suffer as a result of my participation in this race. I also give permission for the free use of my name and/or picture in publication of other accounts of this event.
If participant is under 18, parent/guardian signature is required: Parent/Guardian Signature: ___________________________________ Date:
Relationship to Minor:
Please print out this form and sign before mailing. Forms must be postmarked no later than May 8, 2011. Please make checks payable to Rosary Alumnae Association. Proceeds benefit the Sr. Mary Joseph Scholarship Fund and Rosary High School through the Alumnae Association.
Mail with payment to: Rosary High School Alumnae Department Attn: Road Scholar 5k Run/Walk 901 N. Edgelawn Dr. Aurora, IL 60506-1819
