Mail To: The Tim Russell Memorial Race, Township of Derry, 605 Cocoa Avenue, Hershey, PA 17033

Name:

Address:
City: State: ZIP:

Age: Sex:M F

T-shirt S M L XL

Fun Run/Walk Classes: Male and Female
8 & Under 9 - 14 15 & Over

5K Classes: Male and Female
13 & Under 14 - 19 20 - 29 30 - 39
40 - 49 50 - 59 60 - 69 70 & Over

Pre-Registration ($10.00 - 5K, $8.00 - Fun Run/Walk -by August 12th)
Registration Fee ($15.00 - 5K, $10.00 - Fun Run/Walk -after August 12th)

I would like to donate an additional amount to the Scholarship Fund

$Additional Amount Enclosed

$Total Amount Enclosed.

Please make all checks payable to Township of Derry.

In consideration of acceptance of this entry to the Tim Russell Memorial Run I waive all claims for myself, my heirs and assigns against the sponsors, cooperating and coordinating groups, and any individuals associated with the event and will hold them harmless for any and all injuries or illnesses that may result from my participation. I further state that I am in proper physical condition to participate in this race.

I also hereby give my permission to the media to use my name and/orpicture in any newspaper, broadcast, telecast or any other account of this even without any obligation of anyone to compensate me further therefore.



Participant Signature (Parent, if under 18)

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