April 2, 2016 • Registration 8 AM
Back of Poultney High School, Poultney, VT
Registration Form: (one per person - all information must be complete)
Last Name ______First Name______
Address______
City ______State ______ZIP ______
Home # ______Cell # ______Email ______
Emergency Contact Name: ______Phone Number: ______
Date of Birth ______Male Female (circle one)
T-Shirts to the first 35 runners to register
T-Shirt Sponsor: Donna Johnson Physical Therapy
Registrations accepted in advance by mail
or register in person on race day, April 2nd, 2016
Awards for the first, second, and third men and women, for the top 3 runners under 10 years old, the youngest runner, the oldest runner, and the person who came from furthest away to run. Door prizes drawn from all those who run.
Registration Fees: $15.00 adult, children under 10 free
Please make check payable to: PACC and write “Maplefest Fun Run” on the memo line
Mail to: PACC, Maplefest 2016, P.O. Box 151, Poultney, VT 05741
Waiver: I know that running a race is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running in the event. If the race is cancelled for any reason, I understand that my registration fee is non-refundable. I have read this waiver and know the risks, and hereby waive and release any and all sponsors, their representatives and successors, from all claims or liability arising out of this event. The undersigned further grants full permission to sponsors to use any photographs or other record of this event for any purpose. (Under 18 accepted only with a parent or guardian’s signature)
Signature: ______(required to participate)
Parent/Guardian (if participant is under the age of 18): ______
Date: ______
Contact: Katie Duffy, Katie’s Educational Center,