Mail-in Registration Form
Bobby Bell 5-Mile Road Race
Make Checks Payable To: Lasting Room 5-Mile Road Race
$25 pre-entry, $30 post entry
Mail Entry To: Lasting Room 5-Mile Road Race, c/o Dave LaBrode,
45 Highland Ave Unit B, Haverhill, MA 01830



        State:    Zip: 

Daytime Phone:  Date of Birth:  Age on race date: 

       Gender: M F

       Walk  Run 

 T-shirt Size: S M LG XL XXL
Email: ________________________________________________

Waiver Must Be Read and Signed Before Mailing:
I know that running is a potentially hazardous activity. I should not enter or run this event 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 this race including, but not limited to, falls, contact with other participants, the effects of weather, including high heat and/or humidity, the conditions of the road and traffic on the course, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your acceptance of my application, I, for myself and anyone entitled to act on my behalf, waive and release Andover Striders and The Lasting Room Pub & Deli, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. All fees are nonrefundable.

_______________________________  _____________ _____________________________________

Signature                        Date          Parent's Signature if under 18

Thanks for your support.