First Name:
Last Name:

Email:
Gender:     Male       Female
Birthdate (MM/DD/YYYY):

Address:  
City:   State:   ZIP:  

Phone:

T-shirt size:
(Registration price includes 1 t-shirt, addtl. ones are $10ea.)

Adult sizes: Small Medium Large X-Large XX-Large

Child sizes: Small Medium Large Need more than 1 shirt in the same size? Note that here:

Emergency Contact:

Name: Phone:

Waiver and Release:

In consideration of being allowed to participate in any way in the Pogue's, related events and activities. I acknowledge, appreciate and agree that:

Running and walking a road race is a potentially hazardous activity and the risk of injury does exist. I should not enter unless I am medically able and properly trained. I knowingly and freely assume all such risks both known and unknown even if arising from the negligence of the releasees of others and assume full responsibility for my participation. I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence of participation, I will remove myself from participation and bring such to the attention of the nearest official immediately. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and hold harmless Englewood Community Development Corporation and Englewood Christian Church. With respect to all injury, disability, death or loss or damage to person or property, whether arising from the negligence of the releases or otherwise. I further grant full permission to the above mentioned organizers, and/or agents authorized by them to use any photographs, videotapes, motion pictures, recordings or other record of the event for any reasonable purpose. I have read this release of liability and assumption of risk agreement and fully understand its terms and understand that I have given up substantial rights by signing it. I signed it freely and voluntarily without any inducement.

I understand and agree to the waiver and release.

Please register me for:
5 Mile Run      

2.5 Mile Run/Walk      

Team Name:
(Teams must pay by check -- 1 check/team with the team name in the memo space.)

COST:
$25 - Regular Registration -On or Before June 12th

Form of Payment:
Email me with instructions for making an online Credit Card payment ($2 processing fee )
I will be sending a check or money order.
      Please send payment
      -- made out to ENGLEWOOD COMMUNITY DEVELOPMENT CORP. -- to:

         The Pogue's Run
         Englewood Community Development Corp.
         57 N. Rural St
         Indianapolis, IN 46201

How / Where did you hear about the Pogue's Run?: