ENTRY FORM________

PREREGISTRATION ONLY

KNOBSTONE MINI OCT. 22, 2011

Name__________________________________

Address________________________________

City ____________________St ____Zip______

E-Mail:________________________________

Age_____ Sex____ Phone (____) _____-_____

Check Event: _____ Run OR ____ Walk

Check Distance: __Mini __10 Mi __10K __5K

______$20 Registration Donation (No Race Hat)

______$30 Registration Donation (With Race Hat)

______$10/$20 HHC Member Rate

______$35 Family Rate; Race Hats $10 ea. additional

Race hats are vented, with sweat band, buckle back

______$25 Hikers Council membership (optional)

______Total

Waiver: In consideration of your acceptance of my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Indiana Track Club, the Hoosier Hikers Council, the Indiana Department of Natural Resources, the Counties of Morgan and Monroe, all sponsors and their representatives and successors from all claims or liabilities of any kind arising out of my participation in these club activities.

EMERGENCY PHONE #: ___________________________

Signature_________________________________

Parent or Guardian if under 18

Make check out to the Hoosier Hikers Council Mail to: HHC, P.O. BOX 1327,

Martinsville, IN 46151