REGISTRATION FORM

NAME: ________________________________________________________

STREET ADDRESS: _____________________________________________

CITY, STATE, ZIP_______________________________________________

TELEPHONE: (____)_____________________________________________

EMAIL: ________________________________________________________

AGE: ______ (as of 11/4/07) SEX: M F (circle one)

T-SHIRT SIZE: S M L XL (circle one) – DO NOT CIRCLE IF YOU DON’T WANT A SHIRT

ENTRY FEE: Funds raised will support the Second Harvest Food Bank Network, which serves Clark, Logan and Champaign counties. All participants are encouraged to further show support by bringing a donation of canned food.

______$12.00 pre-registration with t-shirt

______$15.00 race day registration with no shirt guaranteed

______ TOTAL AMOUNT PAID

Make check payable to Wittenberg University 5K Run. Send checks and registration forms, postmarked no later than October 26, 2007 (for pre-registration) to:

Tammy Proctor

History Department, Wittenberg University

P.O. Box 720

Springfield, OH 45501

(937) 327-7841

tproctor@wittenberg.edu

Race will begin at 2:00 p.m. in the area near the Wittenberg University chapel. Parking is available at the Student Center lot at the corner of Ward and Fountain Avenues, or on the streets around the university. Please arrive early for check-in as the race will begin promptly at 2:00 p.m.

Please read and sign the liability statement below:

In consideration of the acceptance of my entry, I, for myself, my executors, administrators and assigners, do hereby release and discharge Wittenberg University, other sponsors and race officials for all claims of damage, demands, actions, whatsoever in any manner, arising or growing out of my participation in said event. I attest and verify that I have full knowledge of the risks involved in this event and I am physically fit and sufficiently trained to participate in the event. Also, I authorize the use of my name and/or photo taken at this race for use in any news media or any form of publicity.

SIGNATURE: ______________________________________________________

(All entries must be signed. If registrant is under 18 years old, a parent/guardian must sign.)