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Printable 2004 Fox Creek 5K Registration Form
[You can fill out this form & print it. It cannot be "submitted" over the Internet.]

Pre-Registration [must be postmarked by July 1]

Pre-registration Fee (Non-refundable) : 
Students under 18 yrs. of age: $8  
Adults: $12

[checks payable to: Town of Berne]

 Fill out this form, print it and send it  by July 1 with your non-refundable fee to:
Race Registration 
P.O. Box 57 
Berne, NY  12023

Day of race registration: starts at 7AM, Town Park  
Fee: Adult: $15  Student: $10

Name: M   F      # leave blank
Age on 7/11/04
Street Address:
City, State, Zip: 
Phone w/ area code: 

Pre-Registered by 7/1/05: Adult $12 Student $8   

Registered Day of Race: Adult $15 Student $10

T-shirt size: XL     L      M      S

Free Park Pentathlon (No T-Shirt, Registration Not Required, Data purposes only)
I Intend to Bring Children 5-12 yrs

Waiver: In consideration for my entry into this race, I do hereby waive and release The Town of Berne and any organizations or individuals officially connected with this event, from any claims or injuries I may incur as a result of my participation.  I understand that interaction with a crowd, or participation in an athletic event has the potential for injury to occur. I testify that I have trained for and am physically fit to participate in this event.  

Signature________________________________________Date: __________
   Parent / Guardian signature required if under 18

Sponsored by the Berne Youth Council

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