Mulvane Old Settlers Road Race

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					        Mulvane Old Settlers Road Race
                            1 Mile and 4 Mile
             NO PETS ALLOWED. SERVICE ANIMALS ONLY.
              Open to runners, joggers, and walkers of all ages.

Name __________________________________________________________

Address ________________________________________________________

City ___________________________________________________________

State ________________________________________ Zip ______________

Phone (work) ____________________________________________________

Phone (home) ____________________________________________________

*Male / Female (circle one) Age (as of August 20, 2011) ______________
       *Not eligible for medal _________
I will be running / walking                         1 mile               4 mile
           (Circle one)                        **Walkers may only walk in ONE race **
T-Shirt – Adult                              S     M      L      XL      XXL
         Youth                               S     M      L

                         T-SHIRTS TO THE FIRST 300 ENTRIES
               T-SHIRT SIZE GUARANTEED IF REGISTERED BY AUGUST 15

                           $10.00 one race - $12.00 both races (one shirt)
                                     Day of race $15.00 (one shirt)

                                (ENTRY FEES ARE NON-REFUNDABLE):

   Send this complete page of the flyer along with the registration fee (checks
 payable to Mulvane Old Settlers Road Race.) Race results will be posted on the
               website at http://skyways.lib.ks.us/ksevents/mosc
               (SHIRTS NOT PICKED UP WILL NOT BE MAILED)

MAIL TO: RACE DIRECTOR, 1466 N. WEBB RD, MULVANE, KS 67110

WAIVER STATEMENT

As an entrant in the 2011 Mulvane Old Settler's Road Race, I assume complete responsibility for
any injury to me or damage to my property which may occur during the event while I am on the
premises of the event; and hereby release and hold harmless the sponsors, promoters or other
persons associated with this event; and I hereby release and hold harmless the sponsors, promoters
or other persons associated with this event, or otherwise. I grant permission to any and all the
foregoing to use any photographs, video-tapes, motion pictures recordings, or any other record of
this event for any purpose whatsoever. (If under 18, parent or guardian must also sign.)

Signature __________________________________________________          Date ____________________

Signature __________________________________________________          Date ____________________
                            (Parent or guardian)


(Photocopies of this entry form will be accepted.)

				
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posted:4/26/2012
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