Running Club at UW-Madison

Valentine’s 5K Run Registration Form

Saturday, February 11^th, 11:00AM at the Natatorium

Please print this form and bring it to the race. Thank you!

Name ________________________________________________________

First Last

Age_____________

________ Male Individual Runner __________Female Individual Runner

________Male Team Member __________Female Team Member

_______________________________ Team Member Name

Entry Fees:

$5 for individual runners

$8 for team entries

WAIVER: In consideration of my participation in the Valentine’s Day 5k run on Saturday, February 11^th, 2006 at the UW Natatorium, hereby release The University of Wisconsin, the Running Club at UW-Madison, UW Recreational Sports, the Board of Regents of the University of Wisconsin System, its officers, employees and agents, from any and all liability for damage to or loss of personal property, sickness or injury from whatever source, legal entanglements, imprisonment, death, or loss of money, which might occur while participating in this event. Specifically, I release said persons from any liability or responsibility for my physical condition, for the condition or selection of course route and for the presence or actions of any other participants. I am aware of the risks of participation, which include, but are not limited to, the possibility of sprained and strained muscles and ligaments, broken bones and fatigue. I hereby state that I am in sufficient physical condition to accept a rigorous level of physical activity. I understand that participation in this program is strictly voluntary and I freely choose to participate. I understand that the University does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur as a result of my participation.

______________________________ ____________________________

(Participant) (Parent or guardian's signature if under l8)

_____________________ _____________________________

(Date) email address