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					                              Turkey Trot 8K Race and Fun Walk Registration Form
                                                                                                                              Essex Lions Club Presents
                                                                                                               2011 8K TURKEY TROT
                                                                                                       SUNDAY, NOVEMBER 20, 2011
                                                                                              Race Starts at 121 Main Street, Essex, MA
                                                                                   Registration: TOP DECK – WOODMAN’S of ESSEX
                                                                                                         Time: 12:00 Noon Walkers Start
                                                                                                       1 p.m. Runners – RACE STARTS

                                                                         Please fill out the registration form and return it along with fee by US Mail to Essex
                                                                           Lions Club, PO Box 79, Essex, MA 01929 or by email to
                                                                       PAYPAL is available online at Fee: Runner = $20 Walkers =
                                                                             $15.00 Late applications (after November 11th = $25. T-Shirts for the first 200

Enter Your Information:
                                                    AGE (DAY OF
LAST NAME              FIRST NAME               SEX RACE)       ZIP               ADDRESS                    CITY             STATE       EMAIL

In Consideration of accepting this entry, I, the undersigned intending to be bound, hereby, for myself, executors, and administrators, waive and release any and all
rights and claims for losses and damages I may have against the sponsor of the race and/or officials of said event, town and state, police and fire department and their
representative, successors and assigns of any and all injuries suffered by me in the said event, I attest and verify that I am physically fit and have sufficiently trained
for the competition of this event and my physical condition has been verified by a licensed physician, Further, I hereby grant full permission to any and all of the
forgoing to use photographs, videotapes, motion pictures, recordings and any other record of this event for any purposes whatsoever.

Signature:                                                                  Date:
If a runner/walker is under 18 years of age Parental/Guardian permission is REQUIRED below:
Signature:                                                                        Date:


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