APPLICATION FOR SEPTEMBER 8, 2012 ROAD RACE Name____________________________________Age_______________________Gender_____________________ Street Address__________________________________________________________________________________ City/Town________________________________State____________________________Zip___________________ E-Mail (optional)________________________________Phone Number____________________________________ In consideration for this race entry being accepted, I hereby for myself, heirs, executors, and administrators, waive and release any and all rights and claims for damages that I may have against the Town Of Dracut, The Dracut Old Home Day Committee, the race directors, all sponsors, and all others associated with this race for any and all injuries suffered by me before, during and after this race. Signature (Parent if under 18)___________________________ If Parent, Print Name Here_____________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Cut Here_ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  Mail Completed Application with fee to: Dracut Old Home Day Committee 5K Road Race  PO Box 217 Dracut, Ma 01826   Entry Fee: $15.00 before 9/8/2012 (Race Day)  $18.00 on Race Day    a. Race day  registration and number pickup starts at 8:30 AM under the canopy in front of Dracut High School, 1540 Lakeview Ave, Dracut b. Race starts at 10:00 AM, Saturday, September 8, 2012 on Lakeview Avenue c. Free T-Shirts to first 50 pre-registered runners. d.  Awards to 1st, 2nd and 3rd overall in male and female groups by age., e. For more information contact the following: 1. ken @dracutoldhomeday.com

DRACUT OLD HOME DAY

A Dracut Community Event Since 2001