Domestic Violence Awareness - Walk/Run Event

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

PLEASE CHECK:    |_| 5K    |_| 10K

Early Registration (before Sept. 19, 2007) $15 ___ (Family of 4 or more) $50 ___
Late Registration (after Sept. 19, 2007) $18 ___ (Family of 4 or more) $60 ___
Long Sleeve Shirt Order (before Friday, August 31, 2007) Pick up day of race.
       Youth ( )S ( )M ( )L // Adult ( )S ( )M ( )L ( )XL (add $2) $14 ___
I would like to donate to the Domestic Violence Awareness Fund:
       ( )$15 ( )$25 ( )$50 ( )$100 ( )$250 ( )$500 ( )Other $___
TOTAL AMOUNT ENCLOSED: $___________

First Name _________________ Last Name _________________

Age (on 9/22/07) _____ Sex |_| M   |_|F

Street Address __________________________________________

City, State, Zip ________________________________________

Day Phone # (_____)______________

e-mail: ______________________

RELEASE
I personally assume all risks incident to my participation in the Marion County Domestic Violence Council's 5k and/or 10k events, including but not limited to, use of the facilities, use of the pathways or streets in and around Minto Brown Park, 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 members of the Marion County Domestic Violence Council and/or member agencies, Gallagher Fitness Resources, the City of Salem, Marion County, and any other sponsors not specifically mentioned, from any and all claims, demands, action, or causes of action incident to my participation in this event (or my child's participation in this event if signing as a parent or guardian). I also understand that the early entry fee is non-refundable and that race mementos are guaranteed only to the first 100 people who pre-register. I grant permission to all the foregoing to use any photographs, video, or any other record of this event for any legitimate purpose. No dogs or wheeled devices in the 5k or 10k events.

Participant's Signature ___________________________________ Date__________

Parent or Guardian's Signature _________________________ (for participants under 18)

Payment must accompany application payable to:
MVWCS-Domestic Violence Awareness Run
Mail to: Gallagher Fitness Resources, 135 Commercial St NE, Salem, OR 97301
Must be received by September 19th, 2007