Registration Form

Name:

Age (on race day):

Gender:

Male Female

Street Address:

City:

State:

Zip code:

e-mail:

Daytime Phone:

Running/Walking

Runner Walker

T-shirt Size*
(Runners only)

Comments:

Register additional runners/walkers at the same address by including their names, ages, and t-shirt size (runners only). Please remember to increase the PayPal amount accordingly.

Change PayPal amount to: $

ONLINE PAYMENT: Our payments are collected by PayPal and you will be sent there upon submission of this form.

Alternatively, you can send a check to:

The David Gallagher Foundation
PO Box 1164
Havertown, PA 19083 (Print Registration Form)

Checks must be received by April 9, 2010
Walkers: $10.00
Runners: $20.00

*T-shirts are guaranteed for runners pre-registered by March 26, 2010

By submitting this form you are agreeing to the following:

WAIVER AND RELEASE OF LIABILITY

I, the registrant, acknowledge that a road race is a physically strenuous and potentially hazardous activity. I certify that I am medically able and have sufficiently trained for this event. I agree to abide by all decisions of the race as final. In consideration of the acceptance of this entry, I hereby agree for myself, my heirs, my executor, and administrators to waive all claims and release and discharge the sponsors, co-hosts, coordinating groups and individuals associated with this event, The David Gallagher Foundation and all other participants from any and all damages, losses or liabilities arising out of my participation in this event.