Please make checks payable and mail to: Worldgate Sport & Health, 13037 Worldgate Drive, Herndon, VA 20170. (Sorry, NO refunds.)

         Name: 

      Address: 

         City: 

        State:    Zip: 

        Phone: 

       E-Mail: 

Date of Birth:    Age on race date: 

       Gender: M F        Event: 5K 1 Mile

   Shirt Size: S M L XL

    Entry Fee: $10 for runners 15 & under $20 Sport & Health Club Member $25 nonmembers 

   After July 1    $25 for all participants

Credit Card No:   Exp: 







VISA/MC ____________    Discover ____________    American Express ____________

Card Holder's Signature:_______________________________________



  

In consideration of my application, I hereby, for myself, my heirs and executors, waive release and forever discharge any and all rights and claims for damages which I may have or may hereafter accrue to me against the organizers and sponsors of the Worldgate Sunrise 5K Run/Walk, and all race sponsors and their representatives, successors and assigns, for any and all injuries suffered by me in said event. I attest and verify that I am physically fit and have sufficiently trained for the competition of this race, and my physical condition has been verified by a licensed medical doctor. Further, I hereby grant full permission to any and all of the foregoing to use my name, photographs, videotapes, motion pictures, recordings or any other record of this event for any legitimate purpose without compensation or reenumeration.

_______________________________  _____________ _____________________________________
 Signature                        Date          Parent's Signature if under 18