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First Name ___________________________ Last Name _______________________

Age ______ BirthDate ___________ Gender ____

Address ________________________________

City ______________________________ State _______ Zip Code __________

Phone _____________________ Email ________________________________

Please check one of the following:

5K Run ____ 2 Mile Walk _____ Fun Run _____

Please check one of the following:

T-Shirt size: Adult S ___ M ___ L ____ XL ____

Child XS ____ S____ M_____ L_____

WAIVER: I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I also know that there may be traffic on the course and assume the risk for running in traffic. I also assume any or all other risks associated with running or attending the race including but not limited to falls, contact with other participants, the affects of the weather and the condition of the roads, all such risks being known and appreciated by me. Knowing these facts, and in consideration of your accepting my entry fee, I hereby for myself, my heirs, executors, administrators or anyone else who might claim on my behalf, covenant not to sue, and waive, release and discharge Barclay Farm Swim Club, and DQ Events and any subcontractors it utilizes, all municipalities in which the race is held, the race committee, volunteers, any and all sponsors including their agents, employees, assigns or anyone acting for on their behalf, or anyone else associated in any way with the race, from any or all claims or liability for death, personal injury or property damage of any kind of nature what so ever arising out of, or in the course of, my participation in this event(s). This waiver extends to all claims of every kind or nature what so ever, foreseen or unforeseen, known or unknown. I HAVE READ AND UNDERSTAND THIS WAIVER: (if under 18, legal guardian must sign)

Must be signed by parent/guardian if participant is under 18

THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNED THIS RELEASE & WAIVER

X____________________________________ Date ________________
(Parent's signature if 18 and under)

Make checks payable to: DQ Events
Mail Checks to: DQ Events
                         P O Box 555
                        Collingswood, NJ 08108