Qdoba
DINO Trail Run Series Entry Form 2012
WHICH
DATE(S) ARE YOU REGISTERING FOR? ____
DISTANCE:
5k___ 15k___ DATE OF BIRTH: m___/ d___/
y___ SEX: M__ F__
LAST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
FIRST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
HAVE YOU
ENTERED A DINO RUN IN THE PAST YEAR? No Yes – if yes you may leave lines below blank,
unless changed.
STREET
ADDRESS: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
CITY:
ZIP: |__|__|__|__|__| PHONE#: (____)|__|__|__-__|__|__|__|
E-MAIL: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
T-SHIRT,
SINGLET, HAT, or SOCKS (additional fee – see below) SIZE: S___ M___ L___ XL___
OPTIONAL:
TEAM/SPONSOR:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
OCCUPATION:
_______________ TIDBIT ABOUT YOURSELF: _____________________________
Total Paid: ____
ALL PARTICIPANTS MUST SIGN BELOW- 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, land owners, and government entities associated with this
off-road event, directed by DINO LLC,
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 Signature:
(If participant under 18 yrs old)
________________________ _________________________ _________________________
Qdoba DINO
Trail Run Series 2012
EVENT# / DATE / CITY / VENUE
1. March 10 Indianapolis, IN Eagle Creek Park
2. April 7 Anderson, IN: Mounds State Park
3. April 28 Indianapolis, IN Town Run Trail
4. June 2 Nashville, IN: Brown County State
Park
5. Aug 25 Indianapolis, IN SouthWestway Park
6. Oct 6 Avon, IN Washington Twp Park
7. Nov 10 Spencer, IN: McCormick’s Creek
State Park
PRICES per event
Note: online entry
is the same price, with no extra fee, no check, no
stamp: www.DINOseries.com/run
|
ITEM |
Early* |
Day-of |
|
|
5k |
$15 |
$20 |
$90 |
|
15k |
$20 |
$25 |
$120 |
|
T-Shirt |
Add $10 |
included |
|
|
Other apparel |
Headsweats cap: $10 Woolie Boolie Socks $10 Air-e-ator Socks $5 |
||
*Early Registration must be received by the
Wednesday before the event.
Mail entry with check payable to: DINO LLC,
PO Box 36395, Indianapolis IN 46236
For the most complete and updated information:
www.DINOseries.com/run
DINO Hotline (317)336-7553 e-mail Brian12@DINOseries.com