CENTERVILLE FIRECRACKER 5K
5K RUN & WALK,
Saturday, July 3th, 2004
8:30 a.m. (Registration - 8 a.m.)
First Midwest Bank, Centerville, SD
Sponsored by the Centerville Chamber of Commerce
This is the 10th year of the Centerville road race.   The course is clearly marked and located in Centerville, SD.  Age divisions are 12 and under, 13-19, 20-29, 30-39, 40-49, 50-59, and 60 & over.  Awards will be given for the 1st, 2nd, and 3rd places in each age division, male and female.  Registration prior to July 3rd is $10 and $12 on the 3rd.  Registration is at 8:00 a.m. at First Midwest Bank in Centerville, SD.  The races begin at 8:30 a.m.

Send registration to:
Bill Hansen, 2201 State Street, Centerville, SD  57014
____________________________(605) 563-2019_____________________________

I certify that I am in good health and have trained for this event, in consideration of your accepting this entry.  I hereby, for myself, any heirs, executor and administrator, waive and release any and all rights and claims for damages I may have against the organization holding this meet, their agents, representatives, successors, and assignors for any and all injuries by me at said meet.

Name (print)____________________ Signature_______________________ M___ F___

Address_________________________ City__________________ State____ Zip______

Telephone_________________ Age (as of race date)________ Type of Race__________

For competitor under 18 years; I the undersigned parent of legal guardian of the competitor, hereby approve and confirm the above waiver and release.

Guardian’s Signature_____________________________