Pemberton 50K Entry Form

PEMBERTON TRAIL 50K ENTRY FORM
February 14th, 2009 @ 7am
NO RACE DAY ENTRIES WILL BE ACCEPTED.

Name__________________________________________________________________________________________________
Relay Partner/Team Name_________________________________________________________________________________
Address________________________________________________________________________________________________
City__________________________________________________________________________State____ Zip______________
Telephone_________________________________________E-mail________________________________________________
Gender___ Age on 2/14/09________
Gender of Relay Partner____ Age on 2/14/09________

Shirt size - (circle one) (Unisex) S M L XL

Entry Fees (includes lunch for entrant (s)):
                  □ 50k Individual                                                                □ 50k Relay (per team)
                          $50 postmarked before January 1                                   $100 before January 1
                          $65 after January 1                                                       $130 after January 1

                  □ Guest Lunch: $7                                                            □ Park Pass: $6
                       # of Guests _____ x $7 = $_____

Total Enclosed $________

WAIVER: I understand that running is a strenuous activity and has some inherent risk. In signing, I give
statement that I am in good health and that there is no medical reason that I should not attempt such a feat. I know
that running on trails in the wilderness poses many hazards; not limited to falls, bad weather, rockslides, wild
animal attack, and generally dangerous conditions not listed. I am entering this event with full knowledge that I
could easily be hurt or face life-threatening injuries. I fully assume all risks of illness, injury or death, and release
covenant not to sue, and discharge McDowell Mountain Regional Park and all sponsors, all food and supplement
suppliers, or other agents from all actions, claims or demands for damages arising out of my participation in this
event. The foregoing release is binding on me personally, as well as upon my heirs, executors, and administrators,
all members of my family who might make claim on my behalf.

Signed_______________________________________________ Date__________

Parent or Guardian______________________________________ Date__________
(If participant is under 18)

Make Checks Payable to: Brian Wieck
Mail to: Brian Wieck, 16828 E. Mirage Crossing Ct. #A- Fountain Hills, AZ - 85268
Questions? Please email Brian at bquick50k@hotmail.com or visit http://www.helenarunningclub.com