Okie Trail Shuffle

Please mail completed application to:
Okie Trail Shuffle
Rt. 4, Box 1195   
Coalgate, OK 74538

For additional information contact RJ or Summer Chiles, (580) 421-6998, email  okietrail@gmail.com

Name _____________________________________                    Male / Female
Address ___________________________________                    City, State, Zip ______________________________________________    
Bib Name __________________________________

9/03/16     50K    Marathon    Half marathon    10K     5K      (circle one)
9/04/16     50K    Marathon    Half marathon    10K     5K      (circle one)
9/05/16     50K    Marathon    Half marathon    10K     5K       (circle one)

Is this your first marathon (26.2 miles)?     Y / N                     Number of completed marathons (26.2 miles)  __________  
Are you a member of the 50 States Marathon club?  Y/N       Member of Marathon Maniacs?   Y/N
Phone (day) ________________ night ________________         Age on race day _____
Email address ___________________________________         Birth date ___________

Fees:

50K                    $75 (thru 5/31)     $85 (6/1 thru race day)
Marathon           $65 (thru 5/31)      $75 (6/1 thru race day)
Half marathon    $55 (thru 5/31)      $65 (6/1 thru race day)
10K                    $40 (thru 5/31)     $45 (6/1 thru race day)
5K                      $30 (thru 5/31)     $35 (6/1 thru race day)

                                                                                                                                                                                                                                          
Make check payable to: Okie Trail Shuffle              Total Enclosed    $ ________

Waiver Must Be Signed
Waiver: All participants in the Okie Trail Shuffle events assume all risk of participation in the marathon by signing the release agreement.  I the undersigned athlete on behalf of myself and on behalf of my heirs, my executors, my administrators and my trustees, waive and release any and all rights and claims for any loss(es), injuries and damages including, but not limited to demands or actions for negligence, premises liability, emotional injury, intentional conduct, tort claims, and any other actions or demands of whatever nature, I have or may have against 1) The Okie Trail Shuffle, 2) its officials, agents and representatives, 3) all sponsors of the event in which I may participate whether my participation is as a contestant or as a spectator.  I acknowledge that I am aware of the inherent risks involved in this event and I voluntarily assume the risks.  I attest and verify that I am physically fit and I have sufficiently trained for the competition of the above-mentioned event in which I participate.  I hereby grant full permission to any and all of the foregoing to use my name, and/or my picture in any account of this event for any purpose whatsoever.  I have read the entry information provided for the event and certify my compliance by signing below.  Athlete acknowledges that the entry fee is non-refundable and non-transferable.
Signature of athlete_______________________________ Date ___________
* Signature of parent/guardian ______________________ Date ___________
*(if athlete is under 18) I certify that my son/daughter has my permission to compete in the Okie Trail Shuffle, is in good physical condition and that race officials have my permission to authorize emergency care if necessary.