Name:__________________________________Age:_________Sex:_______

Street:________________________________________________________

City: ____________________________  State: ______  Zip: ____________

Worcester Resident: ___yes ___no

Phone:___________________                 T-Shirt Size:   M  L XL

I know that running is a potentially hazardous activity.  I should not enter and run in this event event unless I am medically able and properly trained.  I assume all risks associated with running including, but not limited to, falls, contact with other participants, the effects of the weather, including high heat and/or humidity, the conditions of the road and of traffic, all such risks being known and appreciated by me.  Having read this waiver and knowing these facts, and in consideration of your acceptance of my entry for this event  I, for myself and for anyone entitled to act on my behalf, waive and release the organization holding this event and all its agent, sponsors, representatives and successors, from all claims and liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver.

Signature:___________________________________
                  (Parent’s signature required if under 18 years of age)