Second Annual Cummins Run for Literacy
 Please fill in ALL information and mail to:
Run for Literacy 509 Cherry St., Jamestown, NY  14701

I Plan to:  _____ WALK   ______ RUN

Name _____________________________________
Phone  ___________________________________________

Address ___________________________________
 		 City/State/Zip  _____________________________________
Date of birth ___/___/___ Age  ___Gender:   M    F Email Address  ____________________________________

____ I have enclosed my $15 registration fee.  Make check payable to "James Prendergast Library Assoc."
 

____ I would like to be a volunteer on the day of the event
 

____ I am not able to participate or volunteer but would like to make a donation

 

I understand that participating in the Run for Literacy, in any capacity, is a potentially dangerous activity.  I will not take part in the Run for Literacy unless I am medically able and properly trained, and agree to abide by any decision of an official relative to my safety and participation in this event.  I assume all risks associated with this event, and being legally bound, I and anyone entitled to act on my behalf, do hereby waive, release, and forever discharge any claim, action, or dispute against the James Prendergast Library, Cummins, Inc., City of Jamestown, and any and all agencies, individuals, or benefactors acting on their behalf.  I further grant permission to any or all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose.
 

_________________________________  __________________________________________   ______________

        (Print Name)                                                    Signature   (parent/guardian if under 18)               (Date)