PECK PLACE PANTHER POUNCE

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 Town of Orange, Peck Place School & PTO,HI-TEK Racing, 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


LAST NAME:___________________________________________ FIRST NAME: ________________________

SEX: _________ BIRTH DATE: _______________ AGE ON RACE DAY: _______________  

ADDRESS:_____________________________________________________________________

CITY: _________________________________ STATE: ________ ZIP: _____________

TELEPHONE: _________________________ EMAIL: ____________________________________________

T SHIRT: S   M   L   XL                                  

ATHLETE SIGNATURE: ____________________________________________
(parent or guardian must sign if under 18)


ENTRY FEES: $25 Pre-Reg - $35 Race Day (STUDENTS $10.00)
MAKE CHECK PAYABLE TO: Peck Place School PTO
Road Race - Peck Place School PTO
500 Peck Lane
Orange, CT 06477

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