TECUMSEH
TRAIL MARATHON ENTRY FORM 2012
Marathon
Entries subject to field limit of 700
Mail to
& checks payable to: DINO LLC, PO Box 36395, Indianapolis IN 46236
EVENT (circle one):
Marathon $70 ($80 after November 1) ……… Fun Run $10 (no t-shirt or awards)
DATE OF
BIRTH:
m___/d___/y____ SEX: M F
LAST
NAME:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
FIRST
NAME:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
STREET
ADDRESS:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
CITY:
ZIP: |__|__|__|__|__| PHONE#: (____)|__|__|__-__|__|__|__|
E-MAIL: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
LONG
SLEEVE TECH SHIRT (marathon
only) SIZE: S M L XL
EMERGENCY
CONTACT INFO:
NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
PHONE#: (____)|__|__|__-__|__|__|__|
or SPECTATOR AT THE EVENT ___
OPTIONAL:
CUSTOM
FINISHER MEDAL (add $8) Yes / No
TEAM/SPONSOR: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
OCCUPATION: _______________ TIDBIT
ABOUT YOURSELF: _____________________________
Please
read before signing this waiver and release statement. In consideration of the acceptance of my
entry, I for myself, any executors, administrators, and assignees, do hereby
hold harmless all organizations, volunteers, individuals, businesses, sponsors,
and government entities associated with the Tecumseh
Trail Marathon, directed by DINO LLC & Hoosier Hikers Council, for all
claims, damages, actions, whatsoever in any manner arising or growing out of my
participation in said event. I attest
and verify that I am physically fit and sufficiently trained to participate in
this event and assume all risk of participation. Further, I hereby grant full permission of
the foregoing to use my name and photographs of me participating in this event
for any publicity or promotional purposes without obligation or liability to me.
This
constitutes a release and waiver.
Participant Name - Printed: Signature / (Parent
or Guardian if participant under 18 yrs old)