PRINTABLE ENTRY FORM

First Name________________________________ Last________________________________

Address______________________________________________________________________

City_____________________________________________ State_____ Zip_______________

Sex:     M     F             AGE ON RACE DAY___________

Phone #_______________________________ e-mail_________________________________

SHIRT SIZE (100% cotton): S    M         L         XL

ENTRY FEE: $22 RACE DAY: $25

QUESTIONS: (614) 529-9179

MAKE CHECK PAYABLE TO: ULTRAFIT-USA

MAIL TO: ULTRAFIT-USA, PO BOX 06358, COLUMBUS, OHIO 43206

WAIVER

I know that a running event is a potentially hazardous activity, I should not enter unless I am medically able and properly trained, I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with participating in the running event including high heat, humidity, cold weather and wind, traffic and the condition of the road, all such risks being known and appreciated by me. Having read this waiver and knowing those facts and consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release UltraFit/USA, Mount Carmel St. Ann's Hospital, Westerville Parks and Recreation, Westerville Community Recreation Center, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence or carelessness on the part of the persons named on this waiver. By participating in the Westerville Heritage 5K Classic, you allow publication of photos taken at this event with the City of Westerville Parks and Recreation Department.

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ATHLETES SIGNATURE OR GUARDIAN IF UNDER 18: