Seacoast 3,000 & 5,000 Racewalk Sunday, May 17, 2015 USATF-NE Grand Prix Portsmouth High School track - 50 Andrew Jarvis Dr., Portsmouth, NH Registration: 8:45am Race start: 10:00am (both distances) Cut here - Keep Top Portion Seacoast 3,000 & 5,000 Racewalk Entry Form - 2015 Please Print Clearly First Name Address Last Name City Age on 5/17/15 Date of Birth (mm dd yy) State Zip Male Female Email Phone USATF Membership # Team Name Distance you will be racing: 3K 5K I know that racewalking, while an excellent sport, is a potentially hazardous activity, and I am medically able and properly trained to compete in this race. I agree to abide by any decision of race officials relative to my ability to compete safely. I take responsibility for my own actions, and assume all risks associated with this race, including, but not limited to: falls, injuries, death, damage to property, contact with other participants, etc. I, for my heirs, my assigns, and myself, waive and release the City of Portsmouth, Portsmouth High School, New England Walkers, USATF-NE, any and all sponsors, race volunteers, and the State of N.H. from any and all claims and liabilities of any kind whatsoever arising from my voluntary participation in this event, regardless of whether such liability results from the carelessness or negligence of those named in this waiver. All entry fees are non-refundable. Signature (A guardian’s signature is required if the entrant is under 18 years of age) Send completed application and payment to: Seacoast 3,000/5,000 Racewalk c/o Jay Diener 206 Woodland Rd Hampton, NH 03842 Make checks payable to: New England Walkers Entry Fee (non-refundable): $15.00