PLEASE MAKE CHECKS PAYABLE TO "DARE OF SCHUYLKILL COUNTY"

Mail to: DARE Mile Ashland Road Runners

c/o Dennis Kane Tom Lawrence 875-2400

37 South Ninth Street DARE Instructor

Ashland PA 17921 Dennis Kane 875-0837

_________________Cut off and Mail_______________



Place a check mark at your approximate running or walking pace:

Walkers to ten minutes _____ 9 ½ to 8 minutes _____

7 ½ to 6 minutes _____ 5 ½ minutes to Elite _____


Name ____________________________________________________________

Address __________________________________________________________

City ___________________________________ State _____ Zip Code ________

Age (as of 9-8-07) _____ Phone ( ____ ) ____________ Shirt Size S M L XL

DARE Graduate Yes _____ No _____ Current Grade _____

RELEASE FORM MANDATORY

Myself, my minor children, all heirs, successors, and assigns agree to release, waive, and forever discharge from all liabilities and further agree to indemnify, save and hold harmless the Commonwealth of Pennsylvania, the Ashland Borough, the Ashland Road Runners, the Road Runners Club of America, all race personnel, sponsors, directors, The undersigned in consideration of admittance to this activity does hereby release for and any and all assigns of the race from any and all loss, liability, damage, cost which may be incurred before, during, or after this event, due to any participation associated with this activity.


Signature of Participant ___________________________________ Date ___________

Signature of Parent or Guardian if participant is under 18_________________________