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Versailes Run0001
Versailes Run0001
omCAL ENTRYfORM
Name _
Address _
City, State, Zip _
Age (6/25111): Sex: M F T-Shirt size: S M L XL CirCle Qne: Run Wall"
MaKe CheCKpayable to: "Ripley County Chamber Of Commerce
p.O. 'Box 576
Versailles, IN lf70lf2
Any Questions call: 812-689-665'1 or email: ripleYCC@ripleYCoUntYChamber.org
Waiver (must be signed to participate): In consideration Of the acceptance of my entry, 1 hereby waive,
disCharge, and release on behalf of my heirs, executors, and assigns, all claims of any nature arising from mY
participation in the "RiPleyCounty Chamber 5 K Run!WalK and do hereby release the "RiPleyCounty Chamber
of Commerce, and all sponsors, uiorxers, officials, and VOlunteers. 1understand the riSKSinVOlved for
partiCipating in sucn run/walK and have trained adequatelY in preparation. 1give the "RiPleyCounty Chamber
of Commerce permission for use of my name and/or photograph for partiCipating in this event for publicity. I
have noted any medical conditions betoui.
Signature Parent Signature (if under 18) ----c--------
In case Of Emergency Please Contact Phone _~ _