In consideration of your accepting this entry, I , the undersigned, intending to be legally bound hereby, for myself, my heirs, my executors and administrators, voluntarily assume all risks of injury to my person and damage to my property, agree to abide by all ordinances of the City of Carlisle and all rules, regulations and directions, if any, of this event; waive and release any and all rights and claims for damages, I may have against The Leukemia & Lymphoma Society, The City of Carlisle, Carlisle Local Schools, & The Long Memorial 5K Committee, officials, volunteers, successors and assigns for any and all injuries and damages to me or my property in said event; and agree to indemnify, defend and hold those same organizations and individuals harmless from any claims for injury or damage to myself or third person or their property from this event. I attest and verify that I am physically fit and have sufficiently trained for the completion of this race and my physical condition has been verified by a licensed medical doctor. I hereby authorize The Long Memorial 5K Committee and any news media, radio, movie, or TV producer, having permission from acting for the benefit of this event to show and reproduce my name, photograph, pictures and film taken of me by any of those mentioned above.

MAKE CHECKS PAYABLE TO:
THE PATRICK LONG SCHOLARSHIP
P. O. BOX 8233 CARLISLE, OH 45005

PLEASE PRINT CLEARLY

NAME: _________________________________ AGE: ______ GENDER: _______

ADDRESS: ____________________________

TELEPHONE: ____________________

CITY: ________________________ STATE: ______ ZIP: _________