The Third and Final GREAT 1 MILE CHALLENGE

PARENT/GUARDIAN PERMISSION FORM (This form is

required for each challenge)
Date and Time of the 1 Mile Challenge Tuesday, November 22nd from 2:15 to
3:00PM
Where Behind the Andrews Middle School on the soccer fields (race will start and
finish there)

Step 1: Please fill in all information and please write neatly (Form
must be returned by Monday, November 21st)
Student Name: ______________________________________________________
Gender:

(Please Circle One)

Grade: _____________________________________________________________
Parent/Guardian Name: _______________________________________________
Parent/Guardian Phone Number: _______________________________________

Step 2: Review and sign waiver then return to school office or to Mr.
Dowalibys Room #111 .
I hereby for myself, my heirs, executors and administrators, waive and release any
and all rights and claims for damages I may have against Medford Cross Country,
Andrews Middle School, Andrews Middle School Track Club, The Great 1 Mile
Challenge, City of Medford, Medford School Department, as well as any individual
associated with any of the groups mentioned previously for any and all injuries
suffered in connection with this event. I attest that I am physically fit to compete in
this event. Further, I hereby grant full permission to any and all of the foregoing to
use my likeness without personal information in all media including photographs, or
any other record of this event for any legitimate purpose.
Signature: ___________________________________________________________
(A parent or guardian signature is required for entrants under 18 years of age)