Whistleblowers 4K Road race/Fun Run application
Sanctioned by USATF-NE

July 4, 2008 - 10:00 am (Rain or shine!)

july4arrow

To register: Print and mail this form to the address below!

Name:___________________________________ Age: ____ Gender: _____

Address: _______________________________ Circle one:     4K   or   Fun Run

City: ___________________________ State: _______ Zip:__________

Lanesville resident?    circle one:     yes    no

Phone:_____________________ Email: ___________________________

Pricing
before June 15
after June 15
4K road race/BBQ
$13 - includes 5 raffle tickets
$15- 1 raffle ticket
1 mile fun run/BBQ
$5
$6
additional BBQ
$4 ($3 under age 6) x ____
$5 ($3 under 6) x ____
LEAP Donation:               
TOTAL Enclosed    

Make checks payable to: L.E.A.P. Mail to: P.O. Box 7144 Gloucester, MA 01930. No refunds.

Each road race/fun run participant must complete separate application!

4K and Fun Run/Walk Participants Must Sign Waiver:
I know that running is a potentially hazardous activity.  I should not enter unless I am medically able and properly trained.  I assume any and all risks associated with running this event, including but not limited to falls, contact with other participants, the effects of the weather, including high heat or humidity, conditions of the road, and traffic on the route.  Knowing these facts and in consideration of your accepting my entry fee, I hereby for myself, my heirs, executors, administrators or anyone who might claim on my behalf, covenant not to sue, and waive, release and discharge LEAP, the Lanesville Community Center, Town of Gloucester, Essex County, Gloucester Police Department, USATF, and any and all state, county and town officials and employees, race officials, volunteers and sponsors, including but not limited to their agents, employees, assigns or anyone acting on their behalf, from any and all claims for death, personal injury, or property damage or whatsoever, foreseen or unforeseen, know or unknown.  The undersigned further grant full permission to LEAP for the use of any photographs, videotapes, motion pictures, recording, or any other record of this event for any purpose. 

Signature: _____________________  Date:  ______ Parent Signature:  ________________ (under 18)