Address: Apt#:
City: Province: Postal Code:
Telephone:
Sex:
Female
Male Age:
E-mail Address:
Club Name:
Race Date: Sunday, February 28, 2010
1) Fill in information , 2) Print this page 3) Sign & date at bottom,
and 4) Mail registration to:
Attn: Race Registry, YMCA of Peterborough, 123 Aylmer Street S, Peterborough,
ON K9J 3H8
Please ensure the information is completed and accurate. We cannot be responsible for errors made that may affect timing or prizes.
Last Name:
First Name:
Address:
Apt#:
City:
Province:
Postal Code:
Telephone:
Sex:
Female
Male Age:
E-mail Address:
Club Name:
T-shirt Size
| Registration Costs: | 1/2 Marathon | 5K Run/Walk | Kids 1K Fun Run | Kids 1K Camp |
|---|---|---|---|---|
| Before Jan 17th | $45.00 | $30.00 | $15.00 | $10.00 |
| Jan 18th to Feb 14th | $50.00 | $35.00 | $15.00 | $10.00 |
| Feb 15th to 28th | $60.00 | $40.00 | $15.00 | $10.00 |
Cheque Enclosed
MasterCard
Visa
Name on Credit Card:
Card #:
Expiry Date:
Cardholder's Signature:
In consideration of your accepting my entry or the entry of my child or ward, I for myself, my heirs, my child or ward, my executors and administrators of those of my child or ward, do hereby release and forever discharge the Corporation of the City of Peterborough, The Peterborough Family YMCA, YMCA Half Marathon Committee and any or all clubs, associations, supporting companies, competitors and persons associated with the competition from and against any loss or damage, occuring prior to, during or subsequent to the event, to my person or property however caused and notwithstanding that the same may have been contributed to or occasioned by the negligence of any of the aforesaid. By submitting this entry, and signing the box below, I acknowledge having read, understood and agreed to the above release waiver, and indemnity. I warrant that I am physically fit to participate in this event.
Signature Date