Circle of Fun Cross Country Run

Name:____________________________________________ Age:(on Sept 11)____________

Address:________________________________________________ Gender: ___M ___ F

Town:_____________________________________ State:_______ Zip:_____________

Telephone: Day________________________ Evening____________________________

Students: School__________________________________ Grade_______________

Choose one race and enclose check payable to St. Mary School.

Entry fee: $6 if post marked by September 4th of $8 afterward.

I hereby, for myself, my heirs, executors and administrators, waive St. Mary School and the organizers, sponsors, race officials, municipal officials and voluteers of the Circle of Fun Cross Country Run from any claim of damage or injury resulting from my participation in this event, or in traveling to or from this event.

Date____________ Signature________________________________________________

Parent or guardian must sign for runners under 18 years old.

Mail to: Roger Leduc, PO Box 135, Putnam CT 06260