REGISTRATION

RESTON RUNNERS WOMEN'S TRAINING PROGRAM

May 2 – June 20, 2011 (8 sessions)

Mondays, 6:30 to 8:00 p.m.

South Lakes High School, Reston, VA

Cost: $30

Please read the program waiver carefully. Fill out the information below and be sure to include your e-mail address, if you have one, as that will be one or our best means of keeping you informed of program updates. Sign the form. Your signature indicates your understanding and agreement of the program waiver. You must have a signed waiver on file before participating. You may register online at the WTP Info Page, or you may bring this form and payment with you to the first session. ADVANCE REGISTRATION is recommended. Make checks payable to RESTON RUNNERS. You may also mail the signed form and payment to:

Reston Runners (WTP), 12718 Longleaf Lane, Herndon, VA 20170

PROGRAM WAIVER

I know that running and exercise are potentially hazardous activities. I should not enter and run unless I am medically able. I agree to abide by any decision of a program official relative to my ability to safely complete the program. I assume all risks associated with running and exercising in this program 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 or track, 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 the Reston Runners Club, the Fairfax County School Board, Reston Association, the program directors and coaches, all sponsors, their representatives and successors from all claims or liabilities related in any manner to or arising in connection with my participation in this program even though that liability may arise out of negligence or carelessness on the part of the persons named in the waiver. I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this running program for any legitimate purpose.

Name, Age (PLEASE PRINT):  _________________________________________________    _____yrs

If under 18: Consenting Parent/Guardian Name (PLEASE PRINT):

_______________________________________________________

Consenting Parent/Guardian Signature / Date (MM/DD/YY):

______________________________________             ___/___/___

Address:___________________________________________________________ ________________

Phone number: (_______) ________ -- _____________  e-mail address:  _______________________

Emergency Contact (name & phone): ________________________________   (_____) _____-______

Signature & Date: ____________________________________      ____/____/____

Have you previously participated in WTP?   ____YES   ____NO

Please provide any important medical information we should know (allergies, drug reactions, etc.)

___________________________________________________________________________________

___________________________________________________________________________________

How did you hear about the program? (circle one)

RR Web site       Newspaper       Friend       Flyer       Previously Participated      Other____________