TOMMY FUND FAMILY DAY 2012

ENTRY FORM

Last Name _______________________         First Name ______________________

Street _______________________   City _______________________

State ________           Zip ________

Age (on race day) ________              Date of birth                /           /

Male _____                 Female _____              Wheelchair Athlete _____

E-mail  ________________________________________

Waiver: I know that running a road race is a potentially hazardous activity.  I should not enter and run unless I am medically able and properly trained.  I also know that although traffic will be restricted, there will be traffic on the course route.  I assume the risk of running in traffic.   I agree to abide by any decision of any race official as to my ability to safely complete the run.  I also assume any and all other risks associated with running this event, including but not limited to, falls, contact with other participants, effects of the weather, including high temperatures and/or humidity, thunder, lightening, wind, rain or freezing rain, traffic and the conditions of the road, all such risks being known and appreciated by me.  Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf waive and release The Tommy Fund, JB Sports LLC, John Bysiewicz, any race organizing committees and/or board of directors, U.S.A. Track & Field, City of New Haven, race officials, volunteers, and all sponsors including their agents, employees, assigns or anyone acting on their behalf, from all claims or liabilities of any kind arising out of my participation in this event.  I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose.  Application for minors under 18 will be accepted only with a parent's signature.

___________________________________________________________________________

Signature  (Parent’s signature if under 18)

Tommy Fund Family Day Entry Fees:

Early Entry Fee Until:                          Standard Fee Until:                               Race Day:

                                                July 1                                             October 5                                        October 7

5K / 2 Mile Walk                 $25                                                      $27                                                   $30

Kids Race                               $10                                                      $12                                                   $15

Please make checks payable to: Tommy Fund

Send to:           Tommy Fund Family Day

                        2 Buena Vista Rd.

                        Branford, CT 06405