Office Use Only _______________________

A.C. Gilbert's Discovery Village Pumpkin Run

OFFICIAL ENTRY FORM - Only ONE entrant per form    (Please Print Clearly)

PLEASE CHECK:    |_| 5K    |_| Children's Mile

Individual Entry for either event $10 -- Family of 4 or more $35 (individual forms PLEASE)
       Long Sleeve Shirt Size: ADD $14 - Shirt Size: Youth |_|S |_|M |_|L   /   Adult |_|S |_|M |_|L |_|XL
       LATE FEE (after 10/18/07): ADD $3 or $10 for Family
       TOTAL AMOUNT ENCLOSED: $___________

First Name _________________ Last Name _________________

Age (on 10/20/07) _____ Sex |_| M   |_|F

Street Address __________________________________________

City, State, Zip ________________________________________

Day Phone # (_____)______________

e-mail: ______________________

RELEASE
I personally assume all risks incident to my participation in the A.C. Gilbert's Discovery Village 5K, Running and/or Walking Events including, but not limited to, use of facilities, the use of the streets, and all hazards from running or walking in this event. I hereby release for myself, my heirs, executors and administrators, all sponsors of this race including A.C. Gilbert's Discovery Village, Gallagher Fitness Resources, the City of Salem, and any other sponsors not mentioned from any and all claims, demands, action, or causes of action incident to my participation in this event. I also understand that the entry fee is non-refundable and that race mementos are guaranteed only to those who pre-register and pick up their materials prior to the event. I grant permission to all the foregoing to use any photographs, motion pictures, video, or any other record of this event for any legitimate purpose.

Signed ___________________________________ Date__________

Parent or guardian _________________________ (if entrant under 18)

Payment must accompany application payable to:
ACGDV Pumpkin Run
135 Commercial St. NE Salem, OR 97301
MUST BE RECEIVED BY 10/18/07