NAME ______________________________________________

ADDRESS _________________________________________________________

CITY __________________________________ STATE ________ ZIP CODE ____________

AGE ____________    SEX ____________

DATE OF BIRTH ________ PHONE ________________________

SHIRT SIZE     M    L     XL

RACEWALKER:   Y    N            CLYDESDALE    Y      N

Release: I, the undersigned, do hereby knowingly discharge and release; the Township of Freehold, their departments and employees, Freehold Auto Group, The Freehold Area Running Club, The Freehold Centre Committee, the Western Monmouth Chamber of Commerce, The Exchange Club of West Monmouth, the CPL Reynolds Detachment Marine Corps League, Crown Beer Distributors and all sponsors from any and all claims arising out of participation in the event. Further, I represent that I have trained for the event and I am physically able to participate in said event. I further agree to permit race organizers to use any photographs  taken in conjunction with the event for publicity purposes.

Signature __________________________________________     Date ________________

Parent's signature if under 18 ____________________________________________________

make checks payable to : BORN TO RUN ----- PO BOX 224, Tennent, NJ 07763