Entry fees:   5K - $18 before August 15, $20 after

Half Marathon - $22 before August 15, $25 after

Make check payable to Mount Carmel Fitness Challenge, and send to:

Premier Sports, 401 Charmel Place, Columbus, OH 43235

Email: ______________________________________________   

Age:  _______          Gender:   M  / F       

T-shirt:   M     L      XL     XX

Event:     5K         1/2 marathon run           1/2 marathon inline     

Name: ______________________________________________        

Address: _________________________________________________________________

City: _____________________    State:  ____   Zip: _________  Phone:  ______________

Waiver:  I agree that by participating in this physical activity,  or event (the “Event”) or use any Event facility/premises, I do so at my own risk.  I assume all risk of injury, illness, damage or loss to me or my property that might result, including without limitation, any loss or theft of personal property.  I consent to medical treatment in the event of injury, accident and/or illness during the Event.  I agree on behalf of myself (and my personal representatives, heirs, executors, administrators, agents and assigns) to release and discharge the city of Reynoldsburg, Mount Carmel Health Systems, Premier Sports and any and all sponsors from any and all claims or causes of action (known or unknown) arising out of their negligence.  I acknowledge that I have carefully read this Waiver and Release and fully understand that it is a release of liability.  By my signature below, I am waiving any right that I may have to bring legal action to assert a claim against any and all Event sponsors for their negligence.

Signature: ________________________________________________________________

                         (Guardian if under 18)                                                 Date