Name (First & Last): Address:
City:
State: Zip:
Daytime Phone:
Date of Birth:
Age on race date:
Gender: M F
Shirt Size (Circle One):S / M / L / XL
Registration Type: Run Walk
Club/Organization Affiliation[Optional]:
Email [Optional-for next years race mailing]:

Waiver Must Be Read and Signed Before Mailing:
Please enter me as a contestant. In consideration of my being accepted, I hereby for myself, heirs, executors and administrators waive and release any and all rights and claims for damages I may have against the organizers of take the Lake 5K and the Town of Wakefield for any and all injuries suffered by me while competing in and traveling to and from Take the Lake 5K.

_______________________  _________ __________________________
Signature                Date       Parent's Signature if under 18

Mail form & check payable to Take the Lake ($18 before July 1, $20 after) to: 
Take the Lake 5K
PO Box 154
Wakefield, MA 01880
For info: info@takethelake5k.com or phone 781-944 -1156