Last Name:

First Name:

E-mail:

Address:

City:

State:

Zip:             Walk:       Run

 Family Walk

Phone:

Male:     Female:     Age:

Shirt Size:        M             L                   XL

In consideration for accepting this entry, I, the undersigned, intending to be legal bound, for myself, heirs, executers, administrators waive and release any rights and claims of damage I may have against the sponsors, Brown’s Berry Patch, Orchard Dale Fruit Farms and Hospice of Orleans County, as well as all agents, representatives, and successors thereof for any and all injuries or other damages, sustained by me, or any child, at or during the race, or as a result of participating. I give my permission to the organizers to use any photographs, videotapes or other recordings of me that are made during the course of this event. I certify that the competitor is in good health and capable of running/walking this distance. I further agree to abide by traffic rules and regulations.

Signature:

Parent Signature if under 18

Make checks payable to "Hospice of Orleans County" and send to: Browns Berry Patch, 14264 Roosevelt Hwy., Waterport, NY 14571