LAST NAME:_____________________FIRST NAME: __________________________ 
ADDRESS:__________________________________CITY:________________________ 
STATE:___ ZIP:______ PHONE:___________ 
BIRTHDATE: ___/___/___   AGE ON RACEDAY:______    SEX:______
ARE YOU A GMAA MEMBER? (CIRCLE ONE)   yes   no 
IF NO, WOULD YOU LIKE A COPY OF THE LATEST NEWSLETTER?  yes   no 
I WOULD LIKE TO JOIN THE GMAA TODAY:______ ($10 individual/ $15 family) 

TOTAL PAID ________  (include membership if applicable) 

Waiver in the Event of Injury: On consideration of your accepting this entry, I hereby for myself and my heirs, executors and administrators, waive and release any and all rights and claims of damage I may have against THE GREEN MOUNTAIN ATHLETIC ASSOCIATION and all parties involved in the race organization(sponsors,directors,staff, towns,RRCA, or USATF), their successors and assigns, for any and all injuries suffered by me in this race or athletic event. I agree to follow all GMAA and RRCA rules, including not using skates, bicycles, skateboards, baby  joggers, or headphones and not running with a dog.
SIGNATURE:______________________________    DATE:________
IF UNDER 18, PARENT SIGNATURE