Please print application, check all information before mailing, and remember to sign the release form on the bottom.  If you have additional persons registering, please print extra copies.  We request one application per person.  Thank you.

Please Check Age Division.

 Under 14   14-17     18-24     25-29     30-34     35-39     40-44    

 

 45-49    50-54    55+

 

Are you a resident in Marion County?    Yes    No

 

 Male     Female

Name _______________________________  Address __________________________________
 
City _________________________ State _________ Zip _______ Phone ___________________
 
Fax ________________________________ E-mail _____________________________________
 
Date of Birth _____________________________  Age on September 29, 2007 ______________

Shirt Size (Circle One):    XLG    LG    Med    Sm

Entry Fee: $12.00 Pre-registration before September 15 or $15.00 day of race.
Make check payable to: Lebanon-Marion County Chamber of Commerce
Mail to: Pokey Pig 5K, Lebanon-Marion County Chamber of Commerce, 239 N. Spalding Ave, Lebanon, KY 40033-1518

     In Consideration of your accepting my entry, I, intending to be legally bound, do hereby for myself, my heirs, my executors and administrators, waive and release forever any and all rights and claims for damages I may accrue against all persons and agencies - namely, the Lebanon-Marion County Chamber of Commerce and others involved with promoting the race as listing by name, their successors, representatives, and assigns for any and all injuries suffered by me while traveling to and from and while participating in the Pokey Pig 5K:

Saturday, September 29, 2007 in Lebanon, Kentucky

Signature of Entrant ______________________________________ Date: _________________

Signature of Parent/Guardian if entrant is under 18: _____________________________________