Last Name/First Name:_____________________________________

Street Address:___________________________________________

City, State, Zip:___________________________________________

Day Phone/E-Mail:________________________________________

Sex:
___Male
___Female

Date of Birth:______/______/______


Entry Fee:
One Person (Family)...............$10.00. . .$__________

Please Make Checks Payable to: Permian Basin Running Club
. . . . . . . . . . . . . . . . . . . . . . . . . . .4715 W. Wadley Ave. #609
. . . . . . . . . . . . . . . . . . . . . . . . . . .Midland, TX 79707



Release Form: I know that running and volunteering to work in club races are potentially hazardous activities. I should not enter and run in club activities unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running and volunteering to work in club races including, but not limited to, falls, contact with other participants, the effects of the weather, including high heat and/or humidity, the conditions of the road and traffic on the course, all such risks being known and appreciated by me. Having read this waiver, and knowing these facts, and in consideration of your acceptance of my application for membership, I, for myself and anyone entitled to act on my behalf, waive and release the Permian Basin Running Club and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in these club activities, even though that liability may arise out of negligence or carelessness on the part of the person named in this waiver. I also understand that RRCA rules prohibit headphones, baby strollers of any kind, skates or blades and animals in our races. I grant permission to all of the foregoing to use any photographs, video tapes, recordings, or any other record of club events for any legitimate purpose.

Signature___________________________________________________. . . . . .date____________________

Additional signature of parent or guardian if under age 18

Signature___________________________________________________. . . . . .date____________________