OFFICIAL ENTRY FORM

Please print clearly and complete all the information below.
Incomplete or illegible forms will affect your running results.

Please make check payable to “Evan Henry Foundation” and
mail form and payment to: Evan Henry Foundation, PO Box 930, Norwell MA 02061.

This form should be mailed NO LATER THAN Wednesday, May 14th to ensure we receive it in time.

IMPORTANT!: There will be Limited Parking at Norwell High School on Race Day. Shuttle Buses will be available to transport participants from the Hanover Mall to Norwell High School throughout the day.

Entry fee is $20.00 for 5K/10K Road Race and 5K Walk

Entry fee is $10.00 for all the Children's Races
 

Last Name _______________________________
First Name _______________________________
Address _______________________________
City _______________________________
State  _______________________________
Zip Code _______________________________
Daytime telephone (____)   ______________________
E-mail _______________________________
Age On Race Day ________ Gender (M/F) ________
 Race (circle)  10K Race         5K Race         5K Walk       Children's Races
Where did you hear about this race? ___________________________  
 
WAIVER
I hereby for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against The Evan Henry Foundation for Autism and sponsors, coordinating groups and any individuals associated with the event, their representatives and assigns, and will hold them harmless for any and all injuries suffered in connection with this event. I attest that I am physically fit to compete in this event. Further, I hereby grant full permission to any and all of the foregoing to use my likeness in all media including photographs, pictures, recordings or any other record of this event for any legitimate purpose.

Signature (Required: If you are under 18, please have a parent or guardian sign):

_____________________________________  Date: ______________