[FrontPage Save Results Component]Official Entry Form

Make Checks payable to:
The Respiratory Disease Society
And send it to:
The Respiratory Disease Society
P.O. Box 1954
Altoona, PA 16603

In submitting this entry, I intending to be legally bound for myself, my heirs, executors and administrators, waive, release and forever discharge, The Summit, Pepsi, Sheetz, Altoona Mirror, Furrer Beverage, The Respiratory Disease Society, event sponsors, event volunteers and their officers, directors, agents, successors and/or assigns for any and all injuries suffered by me at this event, while traveling to and from the Wallyball Tournament or while participating in the event.  I attest and verify that i am physically fit and sufficiently trained for the competition of this event I understand that I may be photographed and agree to allowing my photo, video or film likeness to be used in any legitimate purpose by the aforementioned parties.

A copy of the official registration and financial information may be obtained from the Pennsylvania Department of State by calling toll free within Pennsylvania 1-800-732-0999. Registration does not imply endorsement.

Name ______________________________

Address _________________________________

City/State _________________________________

Phone (Daytime) _________________________ Age _____

Sex: Male ___ Female ___

Team Name if Applicable ___________________________________

Date _______________