Name:  
 
  Address:  
 
          City:        State:    Zip:  
 
       Email:  
 
  Daytime Phone:  Date of Birth:  Age on race date:        Gender: M F
 
        Event: 10K (6.2 miles)         5K Run (3.1 miles)       Kids' Downtown Mile
 
                   10K Relay Team      5K Walk (3.1 miles)     Corporate Challenge Walk

Registration fee  $20.00 per person for 10K or 5K                         
                                $5.00 per child for Kids Downtown Mile
 Late registration fee  (after June 9,2010):    $30 per person  

Waiver Must Be Read and Signed Before Mailing:
In consideration of my entry to this race. I hereby release and waive any and all claims for damages I may have against The Rutland County Cardiovascular Worksite Wellness Initiative, City of Rutland, Proctor, and all other event sponsors and their representatives, and any officials or participant for any and all injures I may suffer in connection with this race and events associated there with. I also certify that I am in good physical condition and believe that I am fully capable of participating in the running, walking, relay, and fitness events that I choose to take part and have thus trained appropriately for my endeavor. Further, I hereby grant all permission to any and all foregoing to use any photographs, videotapes, motion pictures, recordings, intellectual property or any other record of this event for any purpose.

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  Signature                                                        Date                       Parent's Signature if under 18