In consideration of my entry being accepted intending to be legally bound, I do hereby for myself , my heirs, executors, and administrators waive, release and forever discharge any and all rights for claims and damages, which may have and herein after accrue to me against the TAC of the United States, the Connecticut District TAC, the Saybrook Point 5K Road Race Committee, The Old Saybrook/Westbrook Exchange Club, the Town of Old Saybrook and its commissions, or their officers or agents or assigns which may be sustained and suffered by me in connection with my association with or entry in this event. I further certify that I am in satisfactory physical condition and have made ample preparation for the running of 5,000 meters, or have had a recent physical examination by certrified medical doctor.
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 TAC/USA Number (optional) _____________________________________
SIGNATURE: ____________________________________________
(parent or guradian must sign if under 18)
ENTRY FEES: $20 Pre-Reg By August 17th
$25 After and on race day
MAKE CHECK PAYABLE AND MAIL TO:
Old Saybrook/Westbrook Exchange Club P.O. Box 400 Old Saybrook, CT 06475