Fitzy's 5K Run/Walk
Benefitting Brain Tumor Research & Local Scholarships

Sunday, October 25, 2009 @ 11:00 am
Happy Hollow Playground
Wyomissing, PA

Pre-Race Registration Form

Run Information: (Check event entered)

[ ] 5K Run ($25)   [ ] 1 Mile Fun Walk/Run ($10) 

Shirt Size: (Check One)

[ ] S [ ] M [ ] L [ ] X L    Long-Sleeved T-Shirts to the first 300 registrants for 5K only!

Runner’s Information: Last Name: _________________________________ First Name: __________________

[ ] Male [ ] Female Age on Race Day: _______     Email: _____________________________________

Address: ___________________________________ City: ___________________ State: _______ Zip:_________

In consideration of your permitting me to participate in this event, on behalf of myself, my heirs, executors, administrators, successors and assigns, I hereby waive and release all rights & claims
for damages which I may have against you or your assigns, the municipalities in which the event occurs, or anyone connected with the event, their heirs, executors, administrators, successors,
and assigns, for any and all injuries or illnesses which I may suffer as a result of taking part in the event.  I grant permission to use my name or any audio/visual recording of me for any lawful purpose.
NOTE: Volunteers will be on hand to guide participants, but roads will be open to traffic.

I have read & understand the above waiver.

Signature: ______________________________________________________   Date: _________________

Parent’s Signature (if under 18 years of age): ____________________________________   Date:______________

Please mail completed form by October 17th, along with payment to:

Fitzy's Run, c/o A Running Start
705 Penn Avenue
West Reading, PA 19611

Please make checks payable to "The Lauren Fitzgerald Fund"