Registration Form 

Name __________________________________

Address ________________________________

City/State/Zip ___________________________

E-mail: ________________________________ Phone: ____________   Age (if under 18): ____

Circle:  Male   Female  
Shirt size:  S    M   L    XL   XXL
Event:   Walk    Run     Bike

Entry Fees:
$100 per participant
($25 Entry & $75 Fundraised)

$ _____ enclosed        (circle)   check     Visa     Mastercard
card #: _________________________      Exp. Date: _________ 

AMATEUR Athletic Waiver

I, the undersigned, in consideration of my entry into the 2010 Weymouth FUNday/FUNraiser to be held Saturday September 18, 2010 acting for myself, heirs, personal representatives and assigns, do hereby waive and release any and all claims of damages I may have against Weymouth Rotary Club, the Town of Weymouth and all participating sponsors and supporters for all claims, suits of law or equity for any injury, fatal or otherwise, which may result directly or indirectly to myself, or any loss or losses of personal property that might occur traveling to, from or during my participation in said contest.

I consent to the above mentioned organizations my permission to publish my name, finishing information and/or photo in the media or on the internet. 

________________________________
Signature of participant             Date

 ________________________________
Signature of Parent/Guardian    Date

 Make checks payable and mail to:
Weymouth Rotary Club
PO Box 52
South Weymouth, MA  02190

NO REFUNDS.   FORMS MUST BE RECEIVED BY 8/31/2010.  NO EXCEPTIONS.

 

Office Use Only
Bib #: ______

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