hard-copy entry forms - New Orleans Track Club

39TH ANNUAL LARRY FUSELIER RACE
25K, 5K
December 28, 2014, 8:00 AM
Perfect training race for Rock N Roll (January 25)!
After party at Bucktown Burger and Fish Company!
Mandatory early start for walkers - 7:30 AM
25K and 5K race start - 8 AM
COURSE: Out and back along the Lake Ponchartrain levee path,
starting in Bucktown and returning just past the Treasure Chest
Casino
Online Registration www.runNOTC.org ends 12/21/14
Mail & Faxed registrations must be received by 12/22/14
Mail - NOTC, PO Box 52003, NOLA 70152
Fax - 504.304.2327
In store registration closes 12/18/14
Louisiana Pizza Kitchen Uptown, 615 S. Carrollton Ave
Louisiana Running, 4153 Canal Street
Phidippides Footwear, 6601 Vets Blvd.
Sneaker Shop, 904 Harrison Avenue
Southern Runner, 6112 Magazine Street
Varsity Sports, 3450 Magazine Street
Elmwood Fitness and Running Store, Elmwood Fitness Center
I know that running a road race is a potentially hazardous activity, which could
cause injury or death. I will not enter and participate unless I am medically able
and properly trained, and by my signature, I certify that I am medically able to
perform this event, and am in good health, and I am properly trained. I agree to
abide by any decision of a race official relative to any aspect of my participation in
this event, including the right of any official to deny or suspend my participation
for any reason whatsoever. I assume all risks associated with running in this
event, including but not limited to: falls, contact with other participants, the effects
of the weather, including high heat and/or humidity, and other conditions of the
road, all such risks being known and appreciated by me. I understand that
bicycles, skateboards, baby joggers, roller skates or roller blades, animals, and
headsets are not allowed in the race and I will abide by this guideline. I for myself
and anyone acting on my behalf waive and release the New Orleans Track Club,
Inc. and all sponsor, their representatives and successors from all claims in
liabilities arising out of my participation in the event. I grant permission to use any
photographs, motion picture recordings or any other record of this event for any
legitimate purpose.
______________________________________________________
Print Name
______________________________________________________
Signature of Parent/Guardian if under 18
__________________________
Date
Entry Fees for 25K pre-registered by 12/21/14
NOTC Members - $35
Non-members - $40
12/22/14 THRU RACE DAY - $45
Entry Fees for 5K pre-registered by 12/21/14
NOTC Members - $20
Non-members - $25
12/22/14 THRU RACE DAY $30
NOTC Family - $70/25K and $40/5K
FAMILIES MUST PRE-REGISTER TO RECEIVE THE DISCOUNT: Discount is for
NOTC member families only. Two adults register all family 20 and under living
in household. Separate entry forms required for each family member.
Entry fees are non-refundable. Sorry, no exceptions.
Gloves will be given instead of shirts for this race.
NOTC MEMBER? N Y #____________
RACE (circle one):
RACE #____________
25K
5K
_______________________________________________________
PARTICIPANT NAME
_________________________
DATE OF BIRTH
_____________
AGE RACE DAY
__________________________
E-MAIL ADDRESS
_________
MALE
________
FEMALE
___________________________
PHONE NUMBER
Entry Fee Amount:________________
Circle One – Form of Payment
CREDIT CARD
VISA
CHECK (PAYABLE TO NOTC)
MASTERCARD
AMEX
CASH
DISCOVER
CREDIT CARD NUMBER ________________________________________________
EXP.______________
CVV _______________
NAME ON CARD_______________________________________________________
_________________________________________________________________
ADDRESS
__________________________________________________________________
CITY
STATE
ZIP CODE

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