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Registration Form |
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| Name:___________________________________________ | Walk / Run | (circle one) | |||
| Address:_________________________________________ | City_______________ | State_____ | Zip________ | ||
| Email:___________________________________________ | I hereby absolve and hold harmless the City of Prairie du Chien, the County of Crawford, all sponsors, volunteers, and race officials from any liability for any injury incurred by myself while participating in the Prairie du Chien Half Marathon. I further provide that this consent and waiver applies to my heirs, executors and assignees. I attest and verify that I will participate in this event and my physical condition has been verified by a licensed medical doctor. Further, I grant full permission to nay and all of the foregoing to use my name and any photographs or any other record of me participating in the event for any publicity and / or promotional purposes without obligation or liability. I have read the entry information provided and certify my compliance by my signature below. I also understand entry fees are non-refundable. | ||||
| Age:_____ Sex: M - F Phone:______________________ | |||||
| ______________$45.00 Registration Fee | |||||
| ______________$50.00 (After April 25) | |||||
| ______________Pasta Buffet ($10.00 per person x no. of people) | |||||
| ______________Total Enclosed Check #:_____________ | |||||
| S___ M ___ L___ XL ___T-Shirt size (Please specify) | |||||
| Send Payment to: | |||||
| PDC Half Marathon | |||||
| P.O. Box 394, Prairie du Chien, WI 53821 |
THANK YOU! |
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Signature:________________________ |
Date: |
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