Name ___________________________________________________ Age on race day _____

Address ___________________________________________________________ Sex _____

City ______________________________________________ State _______ Zip ___________

email address: _______________________________________________________________

Phone: _____________________________________________________________________

Wheelchair racer Y ______ N ______
(Wheelchairs must pre-register to ensure safety precaution with local police)

Clydesdale division (males 190 lbs. +) Y ______ N ______

Filly division (females 140 lbs. +) Y ______ N ______

Law Enforcement or Firefighter (specify) ______________________________________
 

Waiver: In consideration of acceptance of this entry, I hereby for myself, heirs, executors, administrations, waive and release all and any rights and claims for damages I may have against the Somerville Road Runners Inc. The City of Somerville, sponsors, race officials, organizers and volunteers associated with this event for any injury that may occur as a result of my participation in this event. I also give permission to use my likeness and publish my name in the news media. I understand that all fees are non-refundable.

_________________________________________________________________________________
Signature: (parent or guardian if under 18)

_________________________________________________________________________________
Date (please print)

$18.00 PRE (BEFORE 3/1/2006); $20.00 POST.

Mail pre-entries to:
Amy Ahearn / Somerville Road Runners, Inc
70 Johnson Street
Framingham, MA, 01701

please makes checks payable to SRR, Inc.