Please fill out this form completely and legibly (print!), and sign the waiver. Mail the form with your check payable to "Leesburg 10K & 20K" to: Leesburg 10K & 20K, 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 July 31, or fax after August 4!

____ 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     Event:   10K    20K   Age on Race Day: ______  


Check if you are a wheelchair athlete: _____


E-Mail Address: ________________________________________________


Phone: (____)_______________    T-Shirt Size:  S   M   L   XL


10K Entry Fee:                  20K Entry Fee: 
$20 on or before July 26        $25 on or before July 26
$25 after July 26               $30 after July 26


Your entry fee includes a race t-shirt, ChampionChip rental, and 
post-race refreshments.


I would like to make an additional donation of $________ to the 
Leesburg 10K & 20K.  Proceeds from the race will benefit Loudoun 
County Adult Respite Center, Blue Ridge Speech and Hearing, 
Every Citizen Has Opportunities (ECHO), Loudoun Interfaith 
Relief, and Loudoun County YMCA.  Thank you for your support!


Credit card: ____________________________________ Exp.__________ 
(Master Card or Visa)




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 Leesburg 10K 
&20K, the Loudoun County YMCA, Northern Virginia Building 
Industry Association, the Town of Leesburg, 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 of the foregoing to use any photographs, 
motion pictures, recordings, or any other record of this event 
for legitimate purposes. I also agree to return my rental 
ChampionChip or pay $35 for its replacement.


Signed: 




________________________________________________________________
Parent or guardian if under 18 years of age          Date

Just print and mail or fax this entry form. We'll have your bib, ChampionChip, and t-shirt when you come to pick up.