Official Entry Form

5 Mile Run / 2 ½ Mile Walk

Saturday, August 14, 2010

Run Start Time: 9:30 a.m. at Cobb Community Center

Walkers immediately following all runners

Registration Fee: $12.00 Early Entry by August 4, 2010

$15.00 After August 4, 2010 (shirt size not guaranteed)

Please sign me up for the: ____ 5 Mile Run OR _____ 2 ½ Mile Walk

Select T-Shirt Size:

Adult: Youth:

____ Small ____ Small

____ Medium ____ Medium

____ Large ____ Large

____ X-Large ____ X-Large

First Name: ________________________ Last Name:____________________________

Address: ________________________________________________________________

City: ____________________ State: _____________________ ZIP: ________________

Email address ___________________ Emergency Phone Number ( )______-_______

_____ Female _____ Male Age as of 8/14/10 ________

Mail official entry form and fee to: Colleen Fingerson

P.O. Box 1

Cobb, WI 53526

Make Checks Payable to: Cobb Corn Roast

In consideration of the acceptance of my entry in the Cobb Corn Roast Annual Fun/Run Walk held on August 14, 2010, I release the Cobb Corn Roast Committee and other individuals or entities who are in any way connected to the event, including any volunteers assisting with the event from any liability or claims for injury or illness that I might sustain during my participation in these events or that is in any other way related to these events. I understand that this release applies to myself and my personal representatives, heirs and assigns. I know that running or walking is a potentially hazardous activity, but represent that I am trained adequately and am medically able. I assume all risks associated with running or walking, including but not limited to falls, contact with other participants, effects of weather including high heat and/or humidity, traffic and the conditions of the roads.

Signature: _______________________________Date: _____ __________________________________

Signature of Parent or Guardian if under 18

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Iowa County Government

http://www.iowacounty.org/

Iowa-Grant School District

http://www.igs.k12.wi.us/