Make Checks Payable to: Brooklyn Road Runners Club

Mail check and form to :

Brooklyn Road Runners Club

P.O. Box 090-108

Brooklyn NY 11209-0002

Name Race:

Brooklyn Road Runners Club member #:

Last Name:

First Name:

Team:

Mailing Address:

City:

State:

Zip:

E-mailaddress:

Age:

Sex:

Phone #

WAIVER OF LIABILITY: I know that participating in BRRC events is a potentially hazardous activity. I agree not to enter and participate unless I am medically able and properly trained. I agree to abide by any decision of an event official relative to my ability to safely complete the event. I am voluntarily entering and assume all risks associated with participating in the event, including, but not limited to, falls, contact with other participants, spectators or others, the effect of the weather, including heat and/or humidity, traffic and the conditions of the course, all such risks being known and appreciated by me. I grant to the Medical Director of this event and his designee access to my medical records and physicians, as well as other information, relating to medical care that may be administered to me as a result of my participation in this event. Having read this Waiver and knowing these facts, and in consideration of your acceptance of this application, I, for myself and anyone entitled to act on my behalf, waive and release Brooklyn Road Runners Club, Road Runners Club of America, USA Track & Field, Knights of Columbus, the City of New York and its agencies and departments, the Metropolitan Athletics Congress, Jack Rabbit, Slope Sports and all sponsors, and their representatives and successors, from present and future claims and liabilities of any kind, known or unknown, arising out of my participation in this event or related activities, even though such claim or liability may arise out of negligence or fault on the part of any of the foregoing persons or entities. I grant permission to the foregoing persons and entities to use or authorize others to use any photographs, motion pictures, recordings, or any other record of my participation in this event or related activities for any legitimate purpose without remuneration.

Signature:

Guardian Signature if under 18:

Date:

Race specific information (E.g.: Fastest Couple name, name of partner):