(To print form, go to your "file" menu and select "print")


Name: ________________________________


Address: ________________________________


City: ________________________________


State: ______   Zip: ______


Telephone: ________________________________


Age on race day: _______ M _____ F________


T-Shirt Size (YS,YM, S, M, L, XL) ____________


CHOOSE YOUR RACE: (Check one)

_____ 5K Run


_____ 5k Racewalk


_____ PeeWee Races


(Baggage Check Available)


I know that running in the Music That Heals Run is a potentially hazardous activity. I should not enter and run uless I am medically able and properly trained. I assume all risks associated with running in the Music That Heals Run, including, but not limited to, falls, contact with other participants, the effect of the weather, including heat and humidity, traffic and conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my application, I, for myself and anyone entitled to act on my behalf, waive and release Music That Heals, Hospital Audiences Inc., the City of New York Department of Parks and Recreation, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver.


Signature: ____________________________


Parent's signature if under 18 years of age:


_________________________________________________


Date: ________________________________


Entry Fee:
Before Sept. 28th:
5K run - $15.00
Pee Wee run - $7.00

Race Day:
5K run - $20.00
Pee Wee run $10.00
Additional Donations are also greatly appreciated

Make check payable to:
Hospital Audiences Inc.
* PLEASE WRITE "MUSIC THAT HEALS" IN YOUR CHECK MEMO

Mail To:
Music That Heals c/o Kathy Lord
P.O. Box 950205