Last Name_______________________________________

First Name_______________________________________

Address________________________________________

City___________________State/Province_____ Postal Code_________

Country (if non USA or CANADA)_______________________________

Age:_______________ Male or Female (circle one)

Phone________________________

E-Mail Address_________________________________

2004 USATF/ATHLETICS CANADA or IAAF MEMBER NATION CARD # (REQUIRED FOR PRIZE MONEY) ______________________________

RACE ENTERED (circle one) (M & W 4K) (W 6K) (M 8K)

WAIVER OF RELEASE (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, the Pacific Northwest Association of USA Track & Field, the City of Seattle, and any and all officials, sponsors, and contributors from any and all liability arising from illness, injury, and damages I may suffer as a result of my participation 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 that my entry fee is non-refundable and non-transferrable. I will pay my own medical and emergency expenses in the event I am ill, injured or otherwise incapacitated and treatment is recommended by the event's volunteers. I believe that I am physically fit to participate in this event, and acknowledge my responsibility to seek medical evaluation if I have any doubts about my fitness for this event

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Participant's Signature_________________________________________________________

Signature of Parent/Guardian if Under 18

__________________________________________

Date _________________

MAKE CHECKS PAYABLE TO:

CLUB BALLARD ATHLETICS, PO Box 70601, Seattle WA 98127-0601 USA

Entry Fee: $10.00 BEFORE 1/20/2004; $15 DAY OF RACE