2014 NEPA AT Scholarship 5K - PreRegistration
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1. Runner Information
IND/Team Leader FIRST Name
Last Name
Email
Phone Number
Sex
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Status
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Emergency Contact Name
Emergency Contact Cell Phone
Emergency Contact's Relation to you?
Will you be entering as part of a Team?
Clear selection
If yes, what is your Team's Name?
Team Leader's Name
Full Name of Team member #2
Full Name of Team member #3
Full Name of Team member #4
We are running in honor of...
or enter your team name
2. Entry Fees
Check ONLY ONE Option
Entry Fee Options *
All fees will be collected onsite. Check or Cash Only
3. Release of Liability
The entry fee is non-refundable;
* Discount is Only Valid off IND Rate
• Entry fee is payable by cash, or check only.
• Please make checks payable to:
 Pennsylvania Athletic Trainers’ Society, Inc.

YOU MUST BE AT LEAST 10 YEARS OLD TO
PARTICIPATE IN BOTH THE WALK AND/OR RUN.
PENNSYLVANIA ATHLETIC TRAINERS’ SOCIETY, INC  THE NORTHEAST PA ATHLETIC TRANING SCHOLARSHIP RUN/WALK  RELEASE OF LIABILITY  (IMPORTANT-READ BEFORE SIGNING)
In consideration for participation for this race and/or any bag or mementos provided, I, the undersigned, intending to be legal bound hereby, for myself, my heirs, executors, and administrators, waive and release any and all
rights and claims for damages I may have against the Pennsylvania Athletic Trainers Society, Inc. (PATS), King’s College, Marywood University, East Stroudsburg University, Alvernia University (collectively “Sponsors”), and any other of the Sponsors’ representatives, agents, affiliates, successors, and assigns, for any and all claims or liabilities of
any kind arising out of my participation in this event, even though that liability may arise out of gross negligence, negligence, or carelessness on the part of the Sponsor.

Realizing that any race or contest is potentially dangerous, I assume all risks associated with participation in the 5K and 1 Mile Challenge, including, but not limited to, falls, contact with other participants, effects of the weather including cold, heat and/or humidity, the conditions of the trail or road, all such risks being known and appreciated by me.

REPRESENTATION OF FITNESS
I attest and verify that I will participate in this event as a race entrant, that I am physically fit and sufficiently trained for the competition of this event, and that any physical condition has been verified by a licensed physician. I
further agree to abide by any decisions of a race official relative to my ability to safely participate.

PERMISSION TO USE VIDEO
Further, I hereby grant full permission to any and all of the aforementioned parties to use my name, likeness, and voice as well as my photographs, videotape, motion pictures, recording, or any other record of this event in which I may appear for any legitimate purpose in advertising and promotion.
I HAVE CAREFULLY READ THIS RELEASE OF LIABILITY, WHEREIN I HAVE ALSO ASSUMED THE RISK OF MY PARTICIPATION IN RECREATION CENTER LEAGUES PROGRAM AND USE OF SPORT EQUIPMENT PROVIDED BY THE ESU SAA FOR SAME, FULLY UNDERSTANDING ITS TERMS, AND UNDERSTANDING THAT BY VIRTUE THEREOF I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND DO HEREWITH SIGN IT VOLUNTARILY AND WITHOUT INDUCEMENT. *
** I recognize that by typing my FIRST MIDDLE and LAST name below it will be considered a valid electronic signature.
Date *
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