Name of Youth (First) ____________________________ Last ______________________ boy girl

Date of Birth __________________________________ Grade on Race Day _______________________

Your e-mail________________________________ Emergency contact phone # _____________________

School Name ____________________________________________________________________________

Is your child attending as part of a school team _________________________, or as an individual _____? (name of team)

T-shirt size: Youth Sm _____ Youth Med _____ Youth Lg _____ Adult Sm _____ Adult Med _____

I think that there are inherent risks and potential for injury when participating in an event such as the Uptown Games, including but not limited to falls, contact with other participants or spectators, effects of weather, conditions on the track or surrounding areas, and physical exertion, and I hereby assume all such risks and responsibility for any and all injury, damage or loss that may result from participation in the Uptown Games. I represent that my child is physically fit to participate in the Uptown Games, and is not subject to any medical condition that poses any risk of harm to him/herself or others. I, for myself, my child, and anyone entitled to act on our behalf, do hereby release the New York Road Runners, Inc., the Armory Foundation, the City and State of New York and its agencies and officials, and all other sponsors of the Uptown Games and the representatives and successors of all of the foregoing, from any and all present and future claims and liabilities of any kind, known or unknown, arising out of my child’s participation in the Uptown Games. I grant permission to the foregoing persons and entities to use or authorize others to use any photographs, motion pictures, recordings, or any other record of my or my child’s participation in the Uptown Games or related activities for any legitimate purpose without remuneration.

Parent/Guardian Signature _____________________________________________ Date ________________

Date Saturday, March 28th, 2015

10:00am-3:30pm

Place New Balance Track & Field Center

at the Armory 216 Ft. Washington Ave.

(btw W. 168th

& W. 169th

) A, C or 1 train to 168

th St.

Time Doors open at 10:00am Same-day registration

closes at 11:00am.

Games begin at 11am

Senator

Adriano Espaillat

Step Fill in your child’s information (please print)

Parent or Guardian read waiver and sign.

Councilmember

Ydanis Rodr iguez

For day-of registration, please arrive at 10am.

Mail: Sen. Adriano Espaillat, attn: David Baily, 5030 B’way, #701 NYC 10034

Fax: 212-544-0256 E-mail: eventsRSVP@adrianoespaillat.org

Step