RECORDS

AGE GROUPS

ENTRY FORM--MEADOWLANDS 5K

Please make checks payable to and mail to:
GSCBC
300 Forest Avenue
Paramus, NJ 07652

Fees:
5K Pre-Registration $17.00 ( $15.00 USATF )
After October 18 $20.00
Walk Pre-Registration $12.00
After October 18 $20.00

Last Name:_________________________________________  First Name:______________________________

Address:_______________________________________

City:__________________________________________

State:________ Zip:____________

Phone:___________________    E-mail:_________________________ 

Circle One:    5K    Walk

Sex:  Male  Female

Age (Day of Race):____________

Date of Birth:_________________

2005 USATF#_________________

T-shirt   S   M   L   XL

Girl Scout Troop #__________

____ I'd like to help fund more programming for the Girl Scouts of Bergen County by purchasing a an Event Booster at $25.00.
Booster Listing___________________________________________

Waiver: I, the undersigned, know that running is a potentially hazardous activity and I should not enter unless I am medically able to and properly trained. Having read this waiver and knowing these facts and in consideration of my entry, I for myself & anyone entitled to act on behalf, waive and release the New Jersey Meadowlands Commission, GS Council of Bergen County, On Your Mark Productions, all their sponsors, representatives & successors from all claims or liabilities of any kind arising out of my participation in this event though the liability may rise out of negligence or carelessness on the part of persons named in this waiver. I further authorize the use of my name and photograph in conjunction with publicity about this event.

Signature (Parent or Guardian if under 18 years of age):

___________________________________________________