Register online *** If registering online, please read the first entry in the FAQ ***  www.speedy-feet.com *** OR  by mail *** OR at early packet pickup *** OR day-of-race


Entry Fee: $20 if received by March 5, 2012 or $25 afterward; CHECKS PAYABLE TO: Harrigan’s 5k Run

MAIL TO: Harrigan’s 5K Run, 1340 Laurelwood Road, Kettering, OH 45409. After March 5th, do not mail your entry because it may not arrive in time – plan to sign up at early registration, or on race day.

Or, DROP OFF at: Up and Running, 6123 Far Hills Ave., Dayton, OH 45459

PLEASE PRINT CLEARLY

First name: ___________________________                           e-mail: ____________________________

Last name: ___________________________                            Telephone: ______-______-____________

Address: _____________________________                           Gender (M/F): ______

City: ________________________________                            Birthdate: __________________________

State: ______________                           Emergency contact name: _______________________________

Zip: ________________                          Emergency telephone #: ______-_______-_____________

Age on race day: ___________             T-shirt size (men’s sizes only):  __________

Wheelchair (Y for wheelchair entry): _____________________

RELEASE AND INDEMNIFICATION

In consideration of your accepting this entry, I hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for liability and damages I may have against the organizers of this event, its agents, sponsors, volunteers, the City of Kettering OH, Harrigan’s Tavern, and their successors and assigns, for any and all injuries or death suffered by me in or arising from said event.  I acknowledge that it is my responsibility to understand the risks and determine whether I am fit to safely complete this event and the precautions I should take. I attest and certify that my physical condition and ability to safely complete this event have been verified by a licensed medical doctor (except where the latter is in violation of religious principles); and that I am physically fit and have sufficiently trained to complete this event. I grant to the organizers, sponsors the exclusive right to use my name, voice and/or picture in any telecast, advertising, promotion, or other account of this event, except when usage suggests endorsement of any product or service without my consent.

Name of parent or guardian if participant is a minor:  ___________________________________

Signature: ________________________________________

Date: ____________________________________________