Salem Park, Recreation & Community Services Department
Present:
The Derby Street Mile Run!
Friday, August 22, 2008 in Salem, Mass, 7:00pm
Race starts on Fort Ave & finishes at Pickering Wharf!
Entry fee: $12 pre-race day $15 on race day, USTFA Certified code MA07017JK
Awesome Technical short sleeve shirts given to first 175 entrants!!
Categories: Male & Female- Children (10 & under 14 & under), Youth (15-18), Open (19-29) (30-39), Masters (40-49), Senior Masters (50+), 60-69, 70 plus, First Salem resident
Awards & Prizes: Trophies to overall winners Male and Female
Medals given to top 5 finishers in each category, raffle prizes from local merchants.
Medals to top 3 male and female finishers from B&Sfitness programs
Post Race: refreshments, food, water, soda, fruit
Information: Contact the Salem Park, Recreation & Communty Services Dept (978) 744-0180 or
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In consideration of this entry being accepted, I hereby for myself, heirs, executers and administrators waive and hereby release any and all rights and claim for damages I may have against the City of Salem Park, Recreation and Community Services Department of any and all injuries suffered at said event, while traveling to or returning therefrom
Name:_______________________________ Age:____ Male:__ Female:__
Address:_________________________________ City:___________ State:_________
Zip:__________Phone:_________________EMAIL:_______________
__ __________________________________ Date:_______tshirt size S__M__L__ XL___
Signature (parent or guardian signature required if under 18 yrs of age)
Send registration & check to: Salem Park, Recreation and Community Services
5 Broad Street Salem, MA. 01970 c/o Derby Street Mile!
PROGRAM ______________________
DATE _______________________________
FEE ________________________________
Name ______________________________________________ Age ________________
Address ________________________________________________________________
Phone ______________________________ Emergency __________________________
E-mail __________________________________________________________________
Liability: The City of Salem Park, Recreation & Community Services Department, School Department and the instructors are not liable
for personal injuries or loss of, or damage to personal property. Since this is a physical activity, injuries may occur. Each student may
decline to participate in any activity and is also responsible to inform the instructor of any physical limitations, which may prevent full
participation in the class.
Signature __________________________________________ Date _________________
Paid ____ Cash ____ Check ____
Please make checks payable to:
The City of Salem Park and Recreation Department
5 Broad Street
Salem, MA 01970
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