Benefiting the Pike Valley Cross Country Team

Scandia, KS 66966
ph: 785-335-2422
john
Entry Fees (Include night running vest, food and drink at aid stations, breakfast following the run)
10 K...............$20
10 Mile..........$20
20 Mile..........$25
30 Mile..........$30
40 Mile..........$35
Pike Valley Alumni Receive a $5 Discount
1. Hightlight the entire form from the title through the name and address at the bottom of the form
2. Click File
3. Click Print
4. Select the Radio Buttom - Print Selection
5. Click OK
.
To enter by mail simply print the form below, sign it and send a check or money order for the appropriate amount to :
John Neal, Lunar Trek
PO Box 28
Scandia, Kansas 66966
Lunar Trek Entry and Release Form
10k, 10-Mile, 20-Mile, 31-Mile (50K), 40.4-Mile Runs
Friday, July 18, 2008 (Full Moon)
Pike Valley High School
Scandia, Kansas
Start 11:00 P.M. ( that is at night )
Name: __________________________________________
Address: ________________________________________
City: _______________________State: _____ Zip: __________________________
E-mail Address: ______________________________________________________
Phone # ____________________
A Nike Running Safety Vest and Swoosh Safety Light is Given to each entrant. Some form of night safety running apparel and or lights is required.
Date of Birth (mm/dd/yy)____/_____/_____ Age on 07/18/2008 _____ Gender (Circle): M F
Number of Ultramarathons completed: ________ Number of trail races completed_________
Race Entry (Check race)
10K ______ 10-Mile_____ 20-Mile _____ 31-Mile(50K)_____ 40.4-Mile_____
_____________ __________________ _____________
Name Address Phone # of Person to Contact in case of an emergency:
WAIVER: By signing below, you agree, warrant and covenant as follows: I know that running and volunteering in running events are potentially hazardous activities. I assume all risk associated with these activities. I hereby waive and release, for myself and anyone entitled to act on my behalf,
The Pike Valley Schools USD 426 and all staff organizers and directors of the Lunar Trek run, and all sponsors and race officials from all claims of any kind arising out of my participation in this event. In consideration of the foregoing, I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns, waive and release any and all rights, claims and courses of action I have or may have against the Lunar Trek Run and USD 426, and any and all sponsors, their representatives and successors, that may arise as a result of my participation in this Lunar Trek Run event and any preand post- event activities. I understand that this event may cause serious bodily harm including broken bones and even death. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event and my physical condition has been verified by a licensed medical doctor. I understand fully that race management can remove me from the race for any legitimate reason they see fit. Be aware that the director(s) and officials of our race event(s) may postpone or cancel said event(s) for safety reasons due to severe weather, high winds, near-by lightning, or "other" serious safety issues. We are not responsible for weather-related and "other" safety issues beyond our immediate control. We reserve the right not to reimburse entry fees for races postponed or cancelled due to safety issues. Further, I hereby grant full permission to any and all of the foregoing to use any photographs of this event for any legitimate purpose including event advertising.
Signature: ______________________________________________________ Date___________
Signature of Parent (if under 18 years old) :_____________________________ Date___________
By signing and submitting this form I agree to wear appropriate a night safety garment and/or safety lighting while participating in the Lunar Trek.
Please sign, date and return the waiver. Make checks payable to “USD 426 Pike Valley Schools” and mail to:
John Neal, Lunar Trek Run, PO Box 28, Scandia, Kansas 66966
Scandia, KS 66966
ph: 785-335-2422
john