12 & under, 13-15, 16-18, 19-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65+

T-Shirt Size (please circle):

Small         Medium          Large          X-Large

Name_____________________________________________

Age___________________

Address___________________________________________

City/State/Zip______________________________________

In consideration of the acceptance of my entry, I waive and release all sponsors and their associates from any claims of damages whatsoever arising out of my participation in the Run For The Roost. I further certify that I am physically fit and sufficiently trained to participate in this event.

Signature (if under 18, parent/guardian must sign):

____________________________________________________

Make payable to:
Run For The Roost
Mail to:
Steve Wright
43 Dempsey Lane
London, KY 40744

This event sponsored by:

Donald K. Johnson, DMD Pepsi Cola Bottling Co. Monumental Life Ins. Gatorade Ormsby Hardware Ford Brothers, Inc.

Senture Ken Sizemore White & Maggard   Orthodontics

Laurel Medical Center Cumberland Valley   National Bank Fellowship of Christian   Athletes