NAME:___________________________________________________________________
ADDRESS:_______________________________________________________________
CITY, STATE, ZIP:_________________________________________________________
PHONE:_____________________________ T-SHIRT SIZE (circle): S M L XL
DATE OF BIRTH:_______________ AGE (on race day):_____ SEX (circle): M F
E-MAIL:__________________________________________________________________
WAIVER: In consideration of and as a condition of my participation in the Chief Ladiga Trail Half Marathon,
I hereby for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages
for personal injuries and otherwise which I may have against the cities of Piedmont, Jacksonville, sponsors and assigns
for and/or claims of liability. I grant permission to everyone to use any photographs or records of this event for media
use or any other legitimate purpose, without compensation to me.
Fee is $15 in advance or $20 on race day.
_________________________________________________________________________
SIGNATURE (Parent or Guardian if under 18 years old) DATE
Make check payable to Jacksonville PARD
and mail with entry form to:
Jacksonville PARD
Chief Ladiga Trail Half Marathon
501 Alexandria Road SW
Jacksonville AL 36265
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