MILLENNIUM MILE REGISTRATION FORM
Please make checks payable to: Millennium Running Company
Mail to: Millennium Running Company
c/o: John Mortimer
PO Box 366
Registration Fees: Adults- $12 pre-race, Kids- $7
Name_____________________________________________________________
Age on race day__________ Gender: M / F
Address___________________________________________________________
City____________________________ State____________ Zip_______________
Phone ____________________ Email __________________________________
Optional Donation to Jack & June Mortimer Memorial Scholarship Fund:
_______________________________
I hereby signify that I understand that the The Millennium Running Company, 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_______________
Millennium Mile Contact Information
John Mortimer, Race Director
PO Box 366
Grantham, NH 03753
Phone: 603-512-1976