Please fill out this form completely and legibly (print!), and sign the waiver. Mail the form with your check payable to "Ivymount School 5K" to: Ivymount School 5K, 13710 Ashby Rd, Rockville, MD 20853-2903. Or, add your credit card number and expiration date, and fax the form to our office at (301) 871- 0006.
Please do not mail the form after October 25, or fax after October 29!

____ I would like to volunteer.
____ I am a ChampionChip owner, and I am deducting $2 from my 
     entry fee. My ChampionChip number is:________________      
     (include full seven-character ID, i.e. CB73466)


Name: __________________________________________________________


Address: _______________________________________________________


City: ___________________________ State: _______ Zip: __________


Sex:  M   F     Age on Race Day: _____    T-shirt:  S  M   L   XL

 
Event:  ____  5K Race    ____ 1 Mile Fun Run/Walk


Phone number:(____)_______________


E-mail address: ________________________________________________



Entry Fee:
$18 through October 28
$22 October 29 through race day
$15 for Ivymount School staff and family (no deadline)
$10 One Mile Fun Run/Walk (no deadline)


____ I would like to make an additional contribution of $_______
     to the Ivymount School.  Thank you for your support!


Credit card: ____________________________________ Exp.__________ 
(Mastercard or Visa only)


Total enclosed or charged: $________




Waiver:
I know that running a road race is a potentially hazardous 
activity and that I should not enter and run unless I am 
medically able and properly trained. I agree to abide by any 
decision of a race official relative to my ability to safely 
complete the run. I assume all risks associated with running in 
this event including, but not limited to, falls, contact with 
other participants, the effects of the weather, including high 
heat and/or humidity, traffic and the conditions of the road, 
all such risks being known and appreciated by me. Having read 
this waiver and knowing these facts and in consideration of your 
accepting my entry, I, for myself and anyone entitled to act on 
my behalf, waive and release the organizers of The Ivymount 
School 5K "Race for Excellence", the Ivymount School, Capital 
Running Company, USATF, and all other sponsors, their 
representatives and successors from all claims or liabilities of 
any kind arising out of my participation in this event or 
carelessness on the part of the persons named in this waiver. 
Further, I grant permission to all the foregoing to use my name 
and images of myself in any photographs, motion pictures, 
results, publications or any other print, videographic or 
electronic record of this event for legitimate purposes.  I also 
agree to return my rental ChampionChip or pay a replacement fee 
of $35.


Signed: 

________________________________________________________________ 
Parent or guardian if under 18 years of age           Date

Don't forget to visit the Ivymount School's Web site at www.ivymount.org!