Last Name:_________________________________________

First Name:_________________________________________

Address:___________________________________________

              ___________________________________________

              City:_____________   State:___________ Zip:_________

E-mail:_____________________________ 

Please Circle:      Male  /  Female

Age________________

Please Circle division you will be running in:

•  Open 
•  U- 18
•  19-29
•  30-39
•  40-49
• 50-59
• 60-69
• 70+
• Clydesdale (over 200lbs)
• wheelchair

Pre Registration $18.00 / $20.00 day of race.

Waiver
In consideration of the foregoing, I, for myself, my heirs, executors, administrators, personal representatives, successors and assigns, waive and release any and all rights, claims and courses of action I have or may have against The Event, its Primary Sponsor and its affiliates, their agents, employees, officers, directors, successors and assigns, the Event Management Company, Inc., the City, the Park District, and any and all sponsors, their representatives and successors, that may arise as a result of my participation in The Event and any pre- and post- event activities. I attest and verify that I am physically fit and have sufficiently trained for the completion of this event and my physical condition has been verified by a licensed medical doctor. Further, I hereby grant full permission to any and all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose including commercial advertising.:   

Your Signature X________________________________________

                                (Guardian if under under 18 years of age)

The Wild Rover Pub     21 Kosciuszko Street,  Manchester,  NH,  03101

 Make checks payable to: The Wild Rover Pub