2004 Official Entry Form
West Bloomfield Half Marathon
5K Run-Walk / Kids Fun Run
Please use one form per participant
Registration Forms may be mailed, faxed or dropped off
Waiver Form MUST be signed

Race Entry Form
Racers Name:  First:   Last: 
Address:
City:
State:
Zip Code:
Daytime Phone:
Date of Birth:
Age on Race day:
Gender: Male
Female
Race Division: Half Marathon
5K Run / Walk
Kids Fun Run
Clydesdale Division (Half Marathon only; Male: 195 lbs and up)
Chip Information:

Note: All participants MUST wear a chip to be scored.		 I will be using a chip provided by the race and understand that I will be
assessed a $30 fee if I do not turn in my chip at the finish.

I own my ChampionChip; my chip number is 
T-Shirt Size (Adults) Medium
Large
Extra-Large
Extra-Extra-Large
Kids Fun Run shirt Size (youth) Medium
Large
Kids Fun Run shirt Size (adult) Small
Large
Entry Fee
Through close of business April 2

T-shirt guaranteed through April 2,
pick up by 12:15 pm on race day
5K Run/Walk $20
Kids Fun Run $10 (ages 5–10)
Half-Marathon $20
Late Registration
After April 2 through race day
No guarantee on T-shirt for late registration
5K Run/Walk $25
Kids Fun Run $15 (ages 5–10)
Half-Marathon $25


Payment MUST accompany Entry Form. We accept Mastercard and Visa, checks (US funds only)

Make checks payable to: West Bloomfield Parks and Recreation

Send to: 4640 Walnut Lake Road, West Bloomfield, MI 48323

Fax #: 248-738-2529

Additional information: Phone 284-738-2500


Credit Card Information (Mastercard or Visa)
Name as it Appears on Credit Card:
Credit Card number:
3 Digit Verification number:
Expiration Date:  MM/YY
Credit Card Signature:


W A I V E R
In consideration of your accepting my entry, I, intending to be legally bound, do hereby for myself, my heirs, executors and administrators, waive and release forever any and all claims I may accrue against the Township of West Bloomfield, West Bloomfield Parks and Recreation Commission, West Bloomfield Schools, and any and all officials and sponsors of this race, their successors, representatives and assigns, for any and all damages and injuries suffered by me while attending and participating in the West Bloomfield Half-Marathon, 5K Run/Walk, and Kids Fun Run. I also authorize the utilization of any photographs and videotape of my participation for any and all purposes.
Signature of participant
(or parent if under 18)
Date Signed:  MM/DD/YY
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