Race Application

I, the undersigned, accept full responsibility for myself and for any injuries that I may incur during the 2012 running of the Wapack Trail Race.  I have read the entire application form and I fully understand that participating in this event may be dangerous to my health.  Sprained ankles, cuts, bruises, and broken bones are real possibilities.  I hereby for myself, heirs, executors, and assigns, waive and release any and all rights and claims for any and all injuries suffered by me, however incurred or sustained, against the organizers, landowners, the Towns of Ashburnham, MA and New Ipswich, NH, the Friends of the Wapack, the Squannacook River Runners, or any race volunteer.  I attest that I am physically fit, I understand the difficulties and hazards of trail running, I have trained sufficiently for the completion of this event, and my actions, mishaps, and medical costs are accountable to no one but myself. 

Signed____________________(Parent or Guardian)  Date______

                                                          (if under 18)

Please print the information below:

Name____________________Age____Date of Birth__________M O F O

Address_________________________________

City/Town_____________________State__________ZIP_____________

Emergency Phone_________________Running Club (opt.)____________

e-mail (opt.) ___________________________

Entry fee:

O $15 if postmarked by 8/25   O $20 after 8/25, including race day

O $5 (Trail Race Directors - pre-registration by mail or e-mail only) Name of Race______________________________

Please make checks payable to Squannacook River Runners

Mail entries to:  Paul Funch, 92 Reedy Meadow Rd., Groton, MA 01450