27th Annual Arbutus Firecracker 10K Run
Saturday, July 4th, 2009 - 8:00 AM Start
Arbutus Middle School, Sulphur Spring Road, Arbutus, MD

Make checks payable to: Arbutus Recreation and Parks Council
Mail to: Arbutus Recreation and Parks Council, PO Box 7437, Arbutus, MD 21227

Do not mail after June 20 - Do not send cash
Type Information, Print, and Sign Entry Form

Event:    10K     1 Mile Fun Run (Free)

Entry Fees
: $20 prior to June 20th
Entry Fees: $25 after June 20th through race day
no confirmations or refunds
First Name:     Last Name:     
City:       State:        Zip:   -
Age on race day:           Sex: F                                                                                              
Date of Birth:   / /
Day Phone:   - -  Evening Phone: - -

I am enclosing my early entry fee in the amount of: $20.00                        $
I am enclosing my late entry fee in the amount of:    $25.00                       $

Waiver/Release Must be Signed Before Mailing:

In consideration of my application being accepted, I hereby for myself, my heirs, personal representatives and executors, waive, release and forever discharge any and all claims for loss or damages which I may have or may hereafter accrue to me against Chsapeake Bank of Maryland, Arbutus Recreation and Parks Council, and all other organizers and sponsors of the Arbutus Firecracker 10K Run, including without limitation any sponsors, patrons or supporters and their respective representatives, successors, and assigns, for any and all injuries which might be suffered by me in said event. I attest and verify that I am physically fit and have sufficiently trained for the completion of this race. Further, I hereby grant full permission to any and all of the foregoing to use my name, photographs, videotapes, motion pictures, recordings or any other record of this event for any legitimate purpose, without compensation or remuneration.

_________________________________________________________     __________
Signature (parent or guardian if under 18)                                                              Date