First Name:

                                Age:

                                  Sex: Select One Female Male

                         Address:

                                City:

                              State:

                                  Zip:

                             Phone:

               Adult Shirt Size: Select One Small Medium Large X Large

                               Event: Select One 5K Mile Fun Run

Waiver:  In consideration of the acceptance of this entry, I waver and release, for myself, my heirs, and my assigns, any and all rights and claims for injury and damage which I might have against the Township of Weathersfield, MMBA, and all sponsors as the result of any and all injuries which I might be received during this contest. I hereby attest and certify that I am physically fit and have sufficiently trained for this run.

        Agree With Waiver: Select One Yes

                        Signature: (parents’ signature if under 18)

  Firefighter Department:

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