Take the Challenge Massachusetts State Association of Emblem Clubs 4 KT/DA

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Name:_______________________

Address:_____________________

City: _______________________

State:_________   Zip:_________

Phone: ___________Email:_________________

Emergency contact:

Name:_______________________ 

Relationship: ________________

Phone:_______________________

I understand that running, walking and biking are stressful events and present participants with hazardous conditions. In consideration of my entry being accepted I, for myself and my heirs, do hereby waive and release all sponsors, directors, communities, the Town of Mansfield MA and other organizations associated with the MSAEC and the KT/DA Take the Challenge on May 1, 2011 of any and all liabilities arising from any and all injuries or damages suffered by me in this event. I also give permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of this event for any legitimate purpose.

Circle your choice of Event:

WALK RUN BIKE WHEELCHAIR or SCOOTER

Circle your Route:     5K(3.1mi)   10K (6.2mi)                  15 or 30 miles (bike only)

Check here ___If you choose to take the VIRTUAL Challenge

T-shirt size:  Circle one S  M    XL  XXL XXXL

Do you wish to receive information by mail on fundraising & recruitment plus local information? ___yes ___no

Registration fee is $25.00 (non-refundable) Make checks payable to MSAEC

SIGNED ________________________________

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THANK YOU for joining us.  Our goal is to raise $300,000 for KT/DA. 

The Massachusetts State Association of Emblem Clubs

our ).

TO PRINT THE FORM above these instructions:

• With your mouse Highlight the area between the ***   *** 
• Click the print button under file on your computer
• Under printer choices ALL  SELECTION  and PAGES
• Choose SELECTION
• Click PRINT

MSAEC - Atten: Julia Durmis