WAIVER:  In consideration of your acceptance of this entry, I hereby release the sponsors/ organizers of this event from any damages, liability or injuries suffered by me as a result of my participation in this event.  I attest and verify that I have full knowledge of the risks involved and I am physically fit and sufficiently trained to participate.  I also give permission for the free use of my name and picture in any broadcast, telecast, or print media account of this event. 

Only one participant per entry form, please.  You may use photocopies.  Make Check Payable to:  CHS Fieldhouse Fund. 

Name:  ___________________________________    Phone:  ______________________________________

Address___________________________________  

             ___________________________________    Signature: ____________________________________

Please Circle:      Male     Female                                      Age Division:    19 & Under     20-29     30-39     40-49     50+

 T-Shirt Size:    S   -  M   -   L  -   XL                                      Event:   Mile Walk     5K Walk     5K Run     10K Run

 Signature of Parent/Guardian  ______________________________    Are you a Thrivent Member   _____ yes  _____no

                 NOTE:  All entrants under 18 must have the entry form signed by a parent