In consideration of the acceptance of this entry, I hereby, for myself, my hiers, executors, adminisrators and assigns, release and discharge sponsors, Fitzwilliam Recreation, Fitzwilliam Inn, Carey Bluhm, and the Town of Fitzwilliam from any injury or loss which may occur during my participation or travel to and from the said event to be held on June 20, 1998. I specifically release and discharge the said pronoters and the Town of Fitzwilliam, whose facilities are being used for this event, etc. from all injuries or damages arising from or contributed to by any physical impairement or defect I may have, whether latent or patent, and agree that, they are under no obligation to provide a physical examination or other evidence of my fitness to participate in such an event, the same being my sole responsibility. I also give my permission for the free use of my name and picture in any broadcast or other written account of the event.

Signature___________________________________Date________

Parent/Guardian(under18)________________________________

Checks made payable to : Friends of Fitzwilliam Recreation

Print out this form,  fill it out, and mail it to  Carey Bluhm, 35 NH Rt 119W, Fitzwilliam, NH 03447