The CIGNA HealthCare Corporate Road Race

Instructions: Complete this form (including your full home mailing address) and sign and date the release waiver. Return the form to your Team Captain as soon as possible. Be sure to read the enclosed information sheets for further details.

OFFICIAL TEAM ENTRY
(Type or print clearly)

Wave Start Group (select one)
[ ] Competitive Runner
(23:00 or faster)
[ ] Recreational Runner
(Slower than 23:00 )
[ ] Walker
If you don't not select a group you will be assigned to the walking group.
[ ] Wheelchair

          
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LAST NAME                     FIRST NAME                   INITIAL
MALE []    FEMALE []       ___________________________
                           AGE ON 8/14/03 DOB(Required)(MoDayYr)
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STREET ADDRESS OR P.O. BOX (Your Residence)	

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CITY                             STATE              ZIP CODE

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COMPANY NAME              TELEPHONE (RESIDENCE)  

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TEAM CAPTAIN'S SIGNATURE  

  SHIRT SIZE M[] L[] XL[] XXL[]

RELEASE/WAIVER: I know that running and road racing are potentially hazardous activities. I will not enter and run in the August 14, 2003, CIGNA HealthCare Corporate 5K Road Race 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 event. I assume all risks associ-ated with participation in this event including, but not limited to, falls, contact with other participants, the effects of the weather including high heat and/or humidity, traffic, and the conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your accepting my application, I for myself and anyone entitled to act on my behalf, waive and release CIGNA Corporation, and all of their affiliates and subsidiaries, Granite State Race Services, The City of Manchester, Veterans Park, all volunteers, all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose. I acknowledge that entry fees are non-refundable and non-transferable for any reason. Athletes who participate in this competition may be subject to formal drug testing in accordance with USA Track & Field rules and IAAF Rule 144. Athletes found positive for banned substances, or who refuse to be tested, will be disqualified from this event and will lose eligibility for future competitions. Some prescription and over-the-counter medications contain banned substances. Information regarding drugs and drug testing may be obtained by calling the USOC Hot Line at 1-800-233-0393. I understand that I am responsible for the return of the ChampionChip® or I will be charged $35.

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APPLICANT SIGNATURE       DATE