* Required Item
First Name:*
Last Name:*
Date of Birth:*
Address:
City:*
State:*
Zip:*
Telephone:*
Cell or Evening Phone:
email:*
Team or School (if any):
Age:*
Category* Start Time DOB Sex Fee
01 11:30 Family Walk   $10
(1 T-shirt and 2 Pasta Party tickets per family)
Divisions based year of birth
02 12 Noon 2009 Girl $10 before 4/6/12
$12 after 4/6/12
03 12:15 2009 Boy
04 12:30 2008 Girl
05 12:45 2008 Boy
06 1:00 2007 Girl
07 1:15 2007 Boy
08 1:30 2005-2006 Girl
09 1:45 2005-2006 Boy
10 2:00 2002-2004 Girl
11 2:15 2002-2004 Boy
12 2:30 1999-2001 Girl
13 2:45 1999-2001 Boy
Divisions based on age
14 2:50 F over 18 Female $12 before 4/6/12
$15 after 4/6/12
15 2:50 M over 18 Male
Additional Pasta/Pizza Party Tickets at $3.00 each:
I would like to help suppport Race Scholarships. I am enclosing my donation of: $

Questionaire:

What do you like about running?

If you ran last year, what did you like best about the race?

Do you have any other comments?

Race Release to be signed by the Parent/Guardian of Participants under the age of 18

I/We, the undersigned parent(s) or guardian(s) of_____________________________, a minor, do hereby CONSENT to his/her participation the Newton Heartbreak Hill Road Race and Walk (hereafter the "Race"). I/We RELEASE and discharge the City of Newton, the Newton Pride Corporation, Newton Community Pride and their respective officers, employees, agents and volunteers (hereinafter collectively "Newton"), and the Race Sponsor(s) from any and all claims, damages, losses or expenses of whatever kind or nature which I/we may have or acquire as the parent(s) or guardian(s) of my child arising out of or resulting, directly or indirectly, from my child's participation in the Race. I/We also RELEASE and discharge Newton and the Race Sponsor(s) from any and all claims, damages, losses or expenses of whatever kind or nature which my child may have or acquire arising out of or resulting from, directly or indirectly, his/her participation in the Race. I/We furthermore agree to defend and INDEMNIFY Newton against any claim, damage, loss or expense of whatever kind or nature that Newton may have to pay that arises from my child's participation in the Race. I also grant permission to Newton and/or the Race Sponsor(s) to use photographs, videotapes, or motion pictures of my child participating in the Race for any purpose whatsoever.

I/We hereby authorize Newton's officier(s), employee(s) or agent(s) who is supervising my child to act on our behalf in authorizing and consenting to emergency medical care for my child if he/she becomes ill or is injured while participating in the Race. This Authorization and Consent may be presented to the appropriate emergency medical staff when emergency medical care is required. I/We hereby RELEASE and discharge Newton, its officers, employees and agents from any and all claims of any nature whatsoever, which may arise out of the decision to provide emergency medical care.

Parent's name: * (if under 18)
I accept the terms of the consent form: Yes No  * (if under 18)


Release to be signed by Participants 18 years of age and older

I, the undersigned, RELEASE and discharge the City of Newton, the Newton Pride Corporation, Newton Community Pride and their respective officers, employees, agents and volunteers (hereinafter collectively "Newton"), and the Race Sponsor(s) from any and all claims, damages, losses or expenses of whatever kind or nature which I may have or acquire arising out of or resulting, directly or indirectly, from my participation in the Newton Heartbreak Hill Road Race and Walk (hereafter the "Race"). I/We furthermore agree to defend and INDEMNIFY Newton against any claim, damage, loss or expense of whatever kind or nature that Newton may have to pay that arises from my participation in the Race. I also grant permission to Newton and/or the Race Sponsor(s) to use photographs, videotapes, or motion pictures of me participating in this event for any purpose whatsoever.

I accept the terms of the consent form: Yes No  *


Platinum Sponsor
Rockland Trust
Silver Sponsor

Cambridge Savings Bank
Sustaining Sponsors
Whole Foods Carvalho & Roth