MOONSHINER 5K ENTRY FORM

Name_____________________________________________________male_________female________

Address_____________________________________________________age (as of 10-16-04) ________

City_____________________________________State______________________Zip______________

Circle T-Shirt Size S M L XL

Fill out completely and mail with entry fee payable to COMMUNITY HOUSE COOPERATIVE
Mail to Community House Cooperative, 115 Mulberry St., Newport, TN, 37821-3522.

ATHLETE'S RELEASE: I know that participating in a race or such event is a potentially hazardous activity and that I should not enter unless medically able and properly trained. I agree to abide by the decision of the event officials relative to my ability to participate safely. I assume all risks including, but not limited to falls, contact with other participants, weather, or other conditions which risks are known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your acceptance of my entry, I waiver and release COMMUNITY HOUSE COOPERATIVE, and all associates and successors from all claims and liability of any kind arising out of my participation in the event even though that liability may arise out of negligence or carelessness on the part of persons named in the waiver. I also grant permission to the foregoing to use my photograph or any recording of this event for any legitimate purposes.

_____________________________________________________ ______________________________________________________ _____________

Athlete's signature----------------------------------------------if under 18, parent's signature----------------------------------date