Entry Form for Northeast Philly 5 Mile Run & 2 Mile Walk 10/17/2010
Please Print
Name_______________________________________ Age on race day_______ Sex______
Address _______________________________________________ City__________________
State_______ Zip_____________ E- Mail__________________________________________
I am participating in the 5 Mile Run_______ 2 Mile Fitness Walk_________ (check one)
T Shirt Size (Youth- S-M-L-XL) __________
The Northeast Philly 5 Mile Run/ 2 Mile Walk supports the Clubs of the Northeast Youth Alliance. If you are interested in having your
proceeds one specific club, please check one.
______ Academy Sabres ______ Calvary AA ______ Parkwood ______Penn Academy
_______ Liberty Bell _______Philadelphia Soccer Club ______Torresdale _____ Penn Crisp
Registration: $15 (pre registration postmark by Oct 12th)
$20 (registration postmarked after Oct 12th)
** Special $8 (pre and post registration) for all youth 14 and under ($10 post)
Checks Payable to : Northeast Phila. Youth Alliance (NEPYA)
Send Registration Form and Checks to: NEPYA
PO Box 63303
Philadelphia, Pa 19114
Disclaimer, Waiver, and Release. In consideration of accepting this entry, the below signed, intending to be legally bound hereby release any and all rights and
claims for damage or injuries that I may have against the Northeast Philly 5 Mile Run/2 Mile Walk, Northeast Phila. Youth Alliance, The City of Philadelphia,
The Northeast Philadelphia Airport, Fast Cat Sports Productions, LLC, and or agents, sponsors, volunteers assisting the event. The release includes all injuries
and all/or damages suffered by me possible during the event.I recognize, intend and understand that the release binding on by heirs, administrators, trustees. I
claim that I have trained for this event and that I am physically fit and cleared by a licensed MD to compete in the race or walk. I also release my likeness to be
used at a later time for promotion of this race and understand there are no refunds for the race.
__________________________________________ ______________
Signature (if under 18 years old, parent or gaurdian) Date