Please Print:

Name __________________________________________________

Street Address ___________________________________________

City _____________________________  State ______   Zip Code __________

Age on Race Day ________   Sex ________  Telephone ______________________

Donation: I can't run , but would like to contribute $_______ to the library

Release: In consideration of the acceptance of my entry, I myself, executors, administrators, and assignees do hereby release and discharge Sally Stretch Keen Memorial Library and other sponsors, organizers or successors from all claims or damages, demands, action and causes of action whatsoever, in any manner arising or growing out of my participation in said road race. I attest that I have full knowledge of the risk involved in this event and I am physically fit and sufficiently trained to participate in this event.

Signature _________________________________________________________

Parent's signature required if under 18 years of age