OFFICIAL PURCHASE FORM
Black and Gold Legends vs. The GHL

Please print clearly and complete all the information below.

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 Friday, January 15th to ensure we receive it and have time to mail your tickets.

General Admission Tickets are $15.00
Last Name _______________________________
First Name _______________________________
Address _______________________________
City _______________________________
State  _______________________________
Zip Code _______________________________
Daytime telephone (____)   ______________________
E-mail _______________________________
Number of Tickets _______________________________
Where did you hear about this event? ___________________________
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: ______________