10th Annual 5K Road Race
Registration Form
Name__________________________________________ Phone___________________________________________
Address___________________________________________ Email____________________________________________
___________________________________________
Age________ Sex: M___F___ T-shirt size: S__M__L__XL__XXL__XXXL__
-Waiver of Responsibility must be signed for registration to be considered valid.
I agree to assume all responsibility for all risk of damage or injury to me as a participant in this event. In consideration of being accepted as an entrant in the North Brookfield Youth Center Road Race/Walk, I hereby, for myself, my heirs, executors and administrators, release and discharge all organizations and individuals associated with the race from all claims, damages, rights of action, present or future, whether the same be known, anticipated, or unanticipated, resulting from or arising out of, or in incident to, my participation in this event. I hereby certify that I will not participate in the run/walk unless I am physically fit and sufficiently trained for completion of the event. I also give permission for the use of my name and/or picture in any broadcast, photograph or other account of this event.
Signature (Required)_____________________________________________________________________________________
Parent Signature (if under age 18)__________________________________________________________________________
Make checks payable to: North Brookfield Youth Center
Mail to:
North Brookfield Youth Center, Attn: Marty Toomey
P.O. Box 86
North Brookfield, MA 01535
Address___________________________________________ Email____________________________________________
___________________________________________
Age________ Sex: M___F___ T-shirt size: S__M__L__XL__XXL__XXXL__
-Waiver of Responsibility must be signed for registration to be considered valid.
I agree to assume all responsibility for all risk of damage or injury to me as a participant in this event. In consideration of being accepted as an entrant in the North Brookfield Youth Center Road Race/Walk, I hereby, for myself, my heirs, executors and administrators, release and discharge all organizations and individuals associated with the race from all claims, damages, rights of action, present or future, whether the same be known, anticipated, or unanticipated, resulting from or arising out of, or in incident to, my participation in this event. I hereby certify that I will not participate in the run/walk unless I am physically fit and sufficiently trained for completion of the event. I also give permission for the use of my name and/or picture in any broadcast, photograph or other account of this event.
Signature (Required)_____________________________________________________________________________________
Parent Signature (if under age 18)__________________________________________________________________________
Make checks payable to: North Brookfield Youth Center
Mail to:
North Brookfield Youth Center, Attn: Marty Toomey
P.O. Box 86
North Brookfield, MA 01535