Live Well 5K

In consideration of acceptance of this entry, I the undersigned intending to be legally bound, do hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against the race director and officials, the City or Town of competition, their representatives, any and all race sponsors and supporters, volunteers, their agents, successors and assigns, for any and all injuries suffered by me in said event. I assume all risks with entering this event, including but not limited to falls, contact with other participants, effects of weather, including high heat and humidity, extreme cold or wind, traffic and the condition of the road. All such risks being known and appreciated by me. I attest and verify that I am physically fit and sufficiently trained for the completion of this event. Further, I hereby grant full permission to any and all the foregoing to use my photographs, videotapes, motion pictures, recordings, or any other record of this event for any legitimate purposes without compensation or remuneration.


PRINT OUT THIS APPLICATION AND MAIL WITH CHECK


CIRCLE:       5K RUNWALK            1.8M UNTIMED  WALK
Milford Hospital Employee?   YES      NO

LAST NAME: ___________________________________________ FIRST NAME: ________________________

EMAIL: _______________________________  (Please include for race updates) 
SEX: ____________ BIRTH DATE: _______________ AGE ON RACE DAY: _______________ ADDRESS:___________________________________________________ CITY: _________________________________ STATE: ________ ZIP: _________ TELEPHONE: ___________________________ T SHIRT SIZE: _____

T SHIRT (circle size): X L M S
SIGNATURE: ____________________________________________
(parent or guradian must sign if under 18)

ENTRY FEES: 	$27 Pre-Reg by May 10 ($20 for those 19 & Under & 70 and Over)
				$30 After and Race Day
MAKE CHECK PAYABLE TO: Milford Hospital - Live Well
Mail To: 
MSRP 245 Laurel Street Stratford, CT 06615

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