First Name: [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
Last Name: [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
SEX:[ ] AGE:[ ][ ] WHEELCHAIR:[ ] LION:[ ] T-SHIRT SIZE (M - L - XL):[ ]
Street Address ______________________________________________
Town:_________________________ State:________ ZIP:__________
Telephone #:_________________ Email:_________________________
In Consideration of accepting this entry, I, the undersigned intending to be legally bound, myself, my heirs, executors and administrators, waive and release any and all rights and claims for losses and damages I may have against the Town of Merrimac and all other parties and their representatives, successors, and assigns for any and all injuries suffered by me in said event. I attest and verify that I am physically fit and have sufficiently trained for this event.
SIGNATURE: (guardian if under 18) ______________________________
DATE: ____________
Pre-registration prior to 8/8 - $10. Registration after 8/8 and race day - $12. Checks payable to: Merrimac Lions Club. Mail form and check to: Merrimac Lions Club, PO Box 179, Merrimac, MA 01860. For more information contact Doug Lay @ (978) 346-9311.
Click here for Merrimac Lions Club 5K Run For Charity information.
