Delano Park 12 Hour Run Registration- 2013

Form must be postmarked by 2/21/13

(Note:    Ultrasignup.com  registrations are discounted by $5  and available later  Visit www.Delano12.com)

Name__________________________________________

Address: _____________________________________________________________

City: ____________________________ State: ___________ Zip: __________

Gender: _______      Birthday:   ____/____/______

Event (Circle):            12 Hour            50 mile        

Individual ($50) _______    

T-Shirt Size (circle):        S     M     L    XL     XXL          

“Centers for Developmentally Disabled, North Central Alabama”   Donation  $______

Email ________________________________________ Phone: ___________________

Emergency Contact Name: _______________________ Phone: __________________

No refunds will be given after January 31st, 2013.

Make checks payable to: “River City Runners”

Mail to: Jon Elmore, 3428 Tanglewood Dr SW, Decatur, AL  35603

Mail-in registrations must be postmarked by 2/21/2013.

I certify that I have decided to participate in the twelve hour run or relay with the full knowledge that being

physically fit and sufficiently trained is necessary to prevent injury to myself, my heirs, devisees, executors,

administrators and assigns. I hereby waive, release and discharge any and all claims against River City

Runners, Inc., the Delano Park 12 hour, the Centers for Developmentally Disabled- North Central Alabama, the Decatur Park and Recreation department, and their employees, agents, or representatives, arising out of my participation in the 12 hour race or relay. I understand that I can receive no refund after 1/31/2011.

Signature: ___________________________________ Date: ______________

Signature of guardian: __________________________ Date: ______________

(Complete if participant is under 18)