HEART BREAKER HALF Entry Form
Sunday, February 19, 2012
World Trade Center, Downtown Portland, Oregon
Half-Marathon Run/Walk, 10K Run/Walk, & 5K Run/Walk
Website - www.racecenter.com/heartbreaker
Email - events@racecenter.com

Official Use Only

Instructions
> Type in your information in the blanks provided.
> Print entry form & SIGN WAIVER (Entry will not be accepted without the signed waiver)
> Make Checks Payable to:
Heart Breaker Half

Mail to:
AA Sports, Ltd
4836 SW Western Ave
Beaverton, OR 97005


Event (Choose One)

ENTRY FEES (entry includes: T-shirt, ChampionChip Timing, awards, prizes, food, festivities, and great camaraderie)


First Name / MI / Last Name

Street Address

City

State/Province

Zip/Postal Code

Birthdate - mm/dd/yy

Age

Gender

Phone

Email

Division (Individuals)

TEAM MUST COMPLETE*
Team Division (Half Marathon only)

Team Name (20 characters or less)

Team Members Names


Long Sleeved Cotton Shirt Size (included with entry fee)

PURCHASE COMMEMORATIVE HOODED SWEATSHIRT FOR $25.00 (must be purchased by Feb 3rd)

PURCHASE COMMEMORATIVE TECH SHIRT FOR $15.00 (must be purchased by Feb 3rd)

I WOULD LIKE TO PURCHASE FINISHER MEDAL FOR $10.00 (must be purchased by Feb 3rd)

Check#

Amount Enclosed



WAIVER MUST BE READ, SIGNED AND MAILED WITH ENTRY
I know that participating in an organized athletic event is potentially hazardous, and that I should not enter to participate unless I am medically able and properly trained. I HEREBY ASSUME THE RISKS OF PARTICIPATING IN THIS EVENT. I certify that I am physically fit and that I have sufficiently trained. I agree to abide by the competitive rules. I hereby take the following action for myself, my executors, administrators, heirs, next to kin, successors and assigns, or anyone else who might claim or sue on my behalf, and I hereby waive, release and discharge from any and all claims, losses, or liabilities for death, personal injury, partial or permanent disability, property damage, medical or hospital bills, or theft which may arise out of or relate to my participation in this event. I agree not to sue, and to hold harmless any and all persons, sponsors, volunteers, participants or government agencies for any and all claims or liabilities that I have waived, released or discharges herein. I understand that my email address will be used for other race promotional purposes.I understand that the Entry Fees are Non-Refundable/Non-Transferable.

Type Full Name


Signature X ___________________________________________________________________
(Signature of Parent or Legal Guardian if participant is under the age of 18)

Date________________________________________