As a condition of the acceptance of my entry. I hereby for myself, my heirs, my executors and administrators waive and release the Alliance for Living, the Town of East Lyme, East Lyme Parks and Recreation Department, Crescent Beach Association, the Old Black Point Association, and the Old Black Point Board of Governors, for any injuries suffered by me while competing in or travelling to and from the event described in this entry form. I certify that I have sufficiently trained for and to the best of my knowledge, am physically fit for this run.
PRINT OUT THIS APPLICATION AND MAIL WITH CHECK
CIRCLE ONE: 10K RUN 5K WALK
LAST NAME: ________________________________________ FIRST NAME: __________________________
TEAM NAME: (IF APPLICABLE): ________________________________________________
SEX: ____________ BIRTH DATE: _______________AGE ON RACE DAY: _______________
ADDRESS:___________________________________________________
CITY: _________________________________ STATE: ________ ZIP: _________
TELEPHONE: ___________________________ EMAIL: _________________________________
T SHIRT: S M L XL COMPETED IN EVERY NB10K SINCE 1999? YES____ NO ____
SIGNATURE: ____________________________________________
(parent or guardian must sign if under 18)
Entry Fees: $20.00 By June 9th - $25 After and on race day
Make check payable to: ALLIANCE FOR LIVING and mail with application to:
Alliance for Living
C/O C. Robbins
P.O. Box 464
Mystic, CT 06355-0464