Entry Form -   Seperate form for each person

Name: ________________________________

Address:_______________________________

__________________________ Zip:________

Home Phone:___________________________

Gender:   M    /    F

Junior (12 years old & under) -  Y    /    N

Entry Fee - $10.00

Bristol 4th of July Committee

Mail entries to:

Troy Paradee
46 Mountain Street
Bristol, VT 05443

I waive and release all rights and claims against the Bristol 4th of July Committee and it's officers and volunteers for any and all injuries, losses or damages suffered while traveling and from or participating in this event, even if the fault of club members or race organizers or volunteers. I assume complete responsibility for loss or damage to my personal possessions during the event. I verify that I am physically fit and sufficiently trained to participate in this difficult competition.

Signature ___________________________