| Entry Form | |||||||||
| 2000 LAKE ATWOOD TEN MILE | |||||||||
| (Entry will be accepted on this form or any facsimile) | |||||||||
| Saturday, October 14, 2000 | |||||||||
| 3:00 P.M. (CDT - Afternoon Race) | |||||||||
| YOUR NAME (Please Print)_______________________________________Male/Female_____________ | |||||||||
| STREET______________________________________________________________________________ | |||||||||
| CITY___________________________________________STATE_____________ZIP________________ | |||||||||
| PHONE (______)_____________________ COUNTY OF RESIDENCE___________________ | |||||||||
| BIRTHDATE: MONTH_______DATE_______YEAR_______AGE DAY OF RACE_________________ | |||||||||
| Day of Race | |||||||||
| RACE ENTERED: | Ten Mile_______ | $ 10.00 | ----------------------------- | $ 12.00 | |||||
| (Check One) | 8K__________ | $ 5.00 | ----------------------------- | $ 6.00 | |||||
| 4K__________ | $ 5.00 | ----------------------------- | $ 6.00 | ||||||
| 2K__________ | $ 3.00 | (10 yrs old & under) | $ 4.00 | ||||||
| YOUR BEST PERFORMANCE -- PAST TWO YEARS | |||||||||
| RACE:_________________________________________ | TIME____________________ | ||||||||
| RACE:_________________________________________ | TIME____________________ | ||||||||
| Other pertinent information (Please write on back of this form) | |||||||||
| In consideration of the acceptance of this entry, I hereby, for myself, my heirs, executors and administrators | |||||||||
| waive and release any and all rights and claims for damages against the City of Atwood, Atwood Township | |||||||||
| County of Rawlins, Atwood Ambassadors and Joe Kanak III (Race Director), their agents, representatives, | |||||||||
| successors and assigns for any and all injuries suffered by me while going to and returning from and competing | |||||||||
| and competing in the 2000 Lake Atwood Ten Mile Road Race (or any of the shorter races) in Atwood, Kansas on | |||||||||
| on October 14, 2000. I certify that I have trained for this event and that I am in adequate physical condition to safely | |||||||||
| participate and complete the race in which I have entered. | |||||||||
| SIGNATURE:______________________________________________ | |||||||||
| Parent or Guardian (if 17 & under)_______________________________________ | |||||||||
| (Entry will not be accepted without signature) | |||||||||
| PLEASE LIST NAME AND ADDRESS OF OTHER RUNNERS YOU KNOW WHO MIGHT BE INTERESTED | |||||||||
| IN RUNNING THIS YEAR IN ATWOOD - Your help will be much appreciated. | |||||||||
| PLEASE MAKE YOUR CHECK PAYABLE TO ATWOOD AMBASSADORS | |||||||||
| PLEASE MAIL THIS ENTRY TO: | |||||||||
| Joe Kanak III | |||||||||
| 403 Garfield | |||||||||
| Atwood, KS 67730 | |||||||||
| Phone: (785) 626-3568 | |||||||||