Last Name

First Name

Sex M F

Age (Raceday)

Address

City

State

Zip Code

Telephone Number --

Individual Entrant: (check 1) 

5K Run	5K judged Race Walk	1 Mile Youth Race
5K Fitness Walk (no awards - just fun)

-or-

2-person 5K Run Teams (check 1)  Male   Female  Mixed

Team Mate Name:

Last Name	First Name
(separate form need for both runners)

Total Team Age (check 1)  50 and under  51-80  81-100  101 and over

READ WAIVER BEFORE SIGNING
In consideration of the opportunity to participate in the Old Chatham Country 5K, I hereby release and forever discharge the Morris Memorial, the Old Chatham Shepherding Company Inn, the Shaker Museum and Library, the Town of Chatham, as well as all even sponsors , their agents and members and any other persons or organization assisting or supporting this event from any claims or other demands as a result of my participating in this event. I hereby for myself, heirs, executors, or assigns, waive and release any and all claims that may arise in my favor against the above named entities and individuals for any injury, illness or property loss which may occur to me while competing in, traveling to, or returning from this event. I realize there are dangers related to participating in a road race and I certify I am in good physical condition and have trained adequately in preparation for my participation, and I am not relying on any medical jusgement or evaluation of the Morris Memorial or any of its Sponsors that I am medically fit to participate in this event.