Last Name_______________________________________

First Name_______________________________________

Address________________________________________

City___________________State/Province_____ Postal Code_________

Country (if non USA or CANADA)_______________________________

Age:_______________ Male or Female (circle one)

Phone________________________

Club Affiliation_________________________________

E-Mail Address_________________________________

Race Entered (check one):

Men's Open 10K_________

Women's Open 6K_________

Men's & Women's 4K & Citizens Race_______

WAIVER (must be signed to compete): In consideration of your accepting my entry, I, intending to be legally bound for myself, my heirs, executors, and administrators do hereby release and discharge, CLUB BALLARD ATHLETICS, Pacific Northwest Track & Field, USA Track & Field, The Seattle Department of Parks & Recreation, and any and all other contributors and sponsors from any and all liability arising from illness, injury, and damages I may suffer as a result of my participating in this event. I also understand that any sponsor may use for publicity of this event, my name and/or pictures of me participating in this event without obligation or liability to me. I have read the entry information provided and certify my compliance by my signature below. I also understand my entry fee is non-refundable and non-transferable.

Athletes who participate in this competition will be subject to formal drug testing in accordance with USATF rules and IAAF Rule 144. Athletes found positive for banned substances, or who refuse to be tested, will be disqualified from this event, and will lose eligibility for future competitions. Some prescriptions and over-the-counter medications contain banned substances. Information regarding drugs and drug testing may be obtained by calling the USOC Hotline at 1-800-233-0393.

Participant's Signature_________________________________________________________

Signature of Parent/Guardian if Under 18__________________________________________

Date _________________

MAKE CHECKS PAYABLE TO:

CLUB BALLARD ATHLETICS, PO Box 70601, Seattle WA 98107-0601 USA

Entry Fee: $10.00 BEFORE 1/21/2002; $15 DAY OF RACE