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St. Francis Stampede Registration Form  
 
Drop off the registration form below by May 9 to the school lobby during school hours
or mail by May 7 to:
Steve Eustis - SFX 5K, 18 Wilkinson Dr, Essex Junction, VT 05452
Make checks payable to St. Francis Xavier School
Cost: $10 adults, $5 kids 14 and under (GMAA members subtract $1)
(Free for 0.2 Mile race, but still fill out this form)
Please enter me in the St. Francis Stampede!

LAST NAME:_____________________FIRST NAME: __________________________ 
ADDRESS:__________________________________CITY:________________________ 
STATE:___ ZIP:______ PHONE:___________
BIRTHDATE: ___/___/___ AGE ON RACEDAY:______ SEX:______
ARE YOU A GMAA MEMBER? (CIRCLE ONE)    yes   no
ARE YOU A ST. FRANCIS PARENT?    yes   no
ARE YOU A ST. FRANCIS TEACHER?    yes   no
IF ST. FRANCIS STUDENT, WHAT GRADE ARE YOU IN?______

TOTAL PAID ________

Waiver: By signing the above, I agree to follow all race rules, including not using skates, bicycles, skateboards, or radio headsets in this events and for myself, heirs, executors, and administrators waive and release any rights and claims for damages I may have against the sponsors, directors, staff, or Winooski for any injuries suffered by me in the St. Francis Xavier Stampede.
SIGNATURE:______________________________    DATE:________
IF UNDER 18, PARENT SIGNATURE
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