Name_____________________________________________________________

Age on race day__________     Gender:  M  /  F

Address___________________________________________________________

City____________________________ State____________ Zip_______________

Phone ____________________ Email __________________________________

Running Club Name _________________________________________________

Optional Donation to Jack & June Mortimer Memorial Scholarship Fund:  

_______________________________

I hereby signify that I understand that Millennium Running LLC, the Millennium Mile, its' organizers and volunteers, the Town of Londonderry, the Millennium Mile sponsors, the area where I run or walk and all other organizations and persons connected with this event are not to be held responsible for any injuries which I may suffer while taking part in this event or as a result thereof. In this connection, I hereby waive any claim for damages to my person or property. I further state that I am in proper physical condition to participate in this event. I grant permission for the organizer to use any photograph or any other record of this event for any legitimate purpose.

Participant's Signature___________________________________Date______________

If under 18,

parent or guardian's signature_____________________________Date_______________