Mail this form with a check for $17.00 per entrant by November 1, 2017, payable to:
Timothy E. Loughlin Scholarship Fund
c/o Betty & Keith Loughlin
91 Exchange Street
Leominster, MA 01453.
(For information call: Betty Loughlin @ 978-407-5644.)
City, State, Zip: ______________________________________
|Walker ___||Runner ___||Male ___||Female ___||Age ___|
|M ___||L ___||XL ___|
I understand that participating in this event is a potentially hazardous activity and I agree to assume all responsibility for all risk of damage or injury to me as a participant in this event. I hereby, for myself, my heirs and assigns, waive any and all rights and claims of action, present or future, whether the same be known, anticipated, or unanticipated, resulting from or arising out of , or in incident to, my participation in this event. I hereby certify that I am physically fit and sufficiently trained for this event. I understand that bicycles, skateboards, baby joggers or strollers, roller skates or blades, dogs, and radio headsets are not allowed in the race and I will abide by this guideline.
(Parent or guardian must sign if participant is less than 18 years of age.)