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
Team or Club [Optional]:
Team Captain [Optional]:
Email [Optional-for next years race mailing]:

Waiver Must Be Read and Signed Before Mailing:
I, for myself, my heirs, executors, administrators, legal representatives, assignees and successors in interest hereby waive, release, discharge, hold harmless, promise not to sue and indemnify: (i) Take the Lake 5K, the New England Coalition for Cancer Survivorship, and the Town of Wakefield, and their respective directors, officers, volunteers, agents and employees; (ii) any event sponsors and organizers; and (iii) all other persons or entities associated with this event from any and all rights and claims including claims arising from the released parties own negligence, which I have or may hereafter accrue to me and from any and all damages which may be sustained by me directly or indirectly in connection with or arising out of, my participation in or association with this event or travel to or from this event.

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

Mail form & check payable to NECCS/Take the Lake ($20 before July 1, $25 after) to: 
Take the Lake 5K
PO Box 154
Wakefield, MA 01880
For info: info@takethelake5k.com or phone 781-944 -1156