Registration Fees:    _____  $16 if pre-registered prior to 6/17/06           _____$20 if registering after 6/17/06

Please Print:

Name:_______________________________________  Sex:_______  Age on (6/25/06):_____  

 

Running Team or Club:_________________________         Check one:   Walker_____    Runner _____   

 

Address:_________________________________  City:___________________________  State:_______  Zip:______________

 

Make Check Payable to: Race Director

Mail to: Wyola Road Race Director, PO Box 542, Shutesbury, MA 01072

 

In consideration of the acceptance of my entry, I myself, my executors, administrators, and assignees, do hereby release and discharge the Town of Shutesbury, the Lake Wyola Association, and any individuals or officials associated with said race from all claims arising or growing out of my participation in said athletic event known as the LAKE WYOLA ROAD RACE.  I attest and verify that I have full knowledge of the risks involved in the event and I am physically fit and sufficiently trained to participate in this event.

 

Signature:  (Parent if under 18)__________________________________   Date:___________________