Bayville 5km Run Registration Form

13th ANNUAL BAYVILLE 5KM RUN REGISTRATION FORM - May 17, 2008
Sponsored by IGA/The Food Basket
To Benefit Breast Cancer at the Women's Center at Huntington Hospital

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FIRST NAME

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LAST NAME

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AGE

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SEX

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ADDRESS

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TOWN

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STATE

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ZIP

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PHONE #

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DATE OF BIRTH

M L XL
SHIRT SIZE

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PHYSICALLY CHALLENGED

The undersigned does hereby acknowledge that he/she is aware of the risks while running a race of 5km (3.107 miles), but is willing to accept said risks and hereby represents and warrants that he/she is in good physical condition and has sufficiently trained for the completion of the run. I hereby release the County of Nassau, Village of Bayville, Finish Line Road Race Technicians, and the sponsors of the the Bayville 5k Run of May 17, 2008 from any injury that I may sustain as a result of my physical condition. I hereby grant permission to use any videotape, photographs, recordings or any other record of this event for any purpose whatsoever.

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SIGNATURE (PARENT IF UNDER 18)

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DATE

Make check payable to Village of Bayville.	($18 prior to May 15, 2008 - $20 Race Day)
Mail to:	Recreation Department Village of Bayville 34 School Street Bayville, NY 11709