Shamrock Scramble Application
All Runners and Walkers Must wear electronic chip on their shoes.
In Consideration of your acceptance of my entry, I, indenting to be legally bound for myself, heirs, executors and administrators do hereby release and discharge WALLKILL ST. PATRICK’S PARADE COMMITTEE, TOWN OF SHAWANGUNK, the race organizers and all sponsors and volunteers from all liability arising from illness, injuries and damages I may suffer as a result of my participation in this event. I do hereby certify that I am physically fit to participate and have trained sufficiently to compete in this event.
Name (print) ___________________________________________________ Male ( ) Female ( )
Street ________________________________________________Phone __________________
City/Town ____________________________________________________ State ________
Zip ________Signature _____________________________________________________
Date _____________Parent Signature(if under 18) _______________________________________
Age on 3/18/2012 ___________*Please enter Age*
High School Name _______________________________
Email ____________________________
Shirt Size ( Please circle): Small Medium Large X-Large
Circle one: Runner Walker Heavyweight Kids Scramble HVGP Member
Please mail application to: Make Checks Payable to:
Al Schmidt Shamrock Scramble 2012
451 Borden Road $20.00 No Refunds $1.00 for Kids Scramble
Wallkill, NY 12589