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Harvest Run Registration Form
Please fill out if you are SPAM BOT

(One form per applicant; please duplicate for additional applicants)


FirstName




LastName


Address

City

State                                                             Zip

Phone


Email


Race Day Age_____________           Sex:   ___  M       ___ F

       Free T-Shirt: (5K and 1M participants)
            __ S        __ M         __ L        __ XL

      Age Category (5K only)
        __   15 & under     __   16-19     __ 20-29        __ 30-39         __ 40-49
       __    50-59             __    60-69     __70-79        __ 80 & over!

      Registration Fee
       __     5K-$15 by October 8,  ($18 after)         __1M-$8  by October 8,  ($10 after)
 
I  release all of the sponsors and organizers of this race from all liability should I suffer any harm from participation in this race. I am physically fit and have prepared for this race and understand the risks involved.I also understand that the race may be canceled if unsafe conditions exist atr acetime andt hat no refunds will be made.


     Mail registration to:

        Ann Phillips, 
       BCC Foundation
       1350 West Street
       Pittsfield, MA 01201

     Telephone:  413-236-2185  

Signature____________________________   
      (PARENT OR GUARDIAN, IF UNDER 18)

Date_________________ 
               
I would like to make a tax deductible gift  of $________________________
to the BCC Foundation to support the nursing program:

Total Enclosed:________________________  
Please make checks payable to BCC Foundation.