The Staten Island Runner

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Run Walk
Personal Information
First Name
Last Name
Age as of July 4th
Date of Birth - month-day-year
Male Female
Address 1
Address 2
City State Zip Code
Phone
Email Address
L XL Shirt Size
Team Type None Open Masters Special
Team Name
Special Olympian
St. Peter's H.S. Alumnus
Notre Dame H.S. Alumnus
By submitting this form I agree to the following:
In consideration for entry in the Pepper Martin/West Brighton Run, I, the undersigned, intending to be legally bound, hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims I may have against the Brighton Kiwanis Club (the sole producer of the race), the race sponsors, organizers and officials, the City of New York, Dept of Parks and Recreation, and their representatives, successors and assigns for any and all injuries suffered by me in said event and my physical condition has been verified by a licensed doctor. Further, I hereby grant full pernission to any and all of the foregoing to use any photographs, videotapes, motion pictures, recordings, or any other record of this event for any legitimate purpose. THE RACE DIRECTORS RESERVE THE RIGHT TO REJECT ANY ENTRY.
There will be a $1.95 processing fee for online application.