Please enter me in the Clarence DeMar (07/05/14)
LAST NAME:_____________________FIRST NAME: __________________________
ADDRESS:__________________________________CITY:________________________
STATE:____ ZIP:_________ PHONE:________________
EMAIL:_________________________________________
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)
List Family Members Below if Joining as a Family
NAME:_____________________ SEX:____ BIRTHDATE: ___/___/___ EMAIL:___________________________
NAME:_____________________ SEX:____ BIRTHDATE: ___/___/___ EMAIL:___________________________
NAME:_____________________ SEX:____ BIRTHDATE: ___/___/___ EMAIL:___________________________
NAME:_____________________ SEX:____ BIRTHDATE: ___/___/___ EMAIL:___________________________
NAME:_____________________ SEX:____ BIRTHDATE: ___/___/___ EMAIL:___________________________
T-SHIRT SIZE: S M L XL
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 radio headsets
and not running with a dog.
SIGNATURE:______________________________
DATE:________
IF UNDER 18, PARENT SIGNATURE |