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(  ) Unattached   (  ) Member of Track Club ___________________________________

Checks payable to:  Middletown Parks & Recreation. 
Mail copy of entry form and check to: Patti Miller, 106 Murray St., Middletown, CT 06457
Circle Fee: $7 Early-Bird   $10 On-Site  $5 Middletown Residents, $3 1-mile Open,  $1 Pee-Wee

Athlete’s Release: In consideration of your acceptance of my entry into the Mid-Summer Youth All Comers Meet, I voluntarily agree to participate in the  Mid-Summer Youth All Comers Meet and knowingly assume any and all risk of loss, damage, property loss, injury (including death), both foreseen and unforeseen, of my attendance at and participation in the Mid-Summer Youth All Comers Meet, from any cause whatsoever. I, for myself, my heirs, personal representatives and assigns do hereby release, waive, discharge and covenant not to sue USA Track & Field, Inc., the USATF Connecticut Association, the Connecticut Track Club, Middletown Parks & Recreation, and/or Middletown Board of Education  (collectively “Releases”) from all liability, loss, claims, demands, possible causes of action, court costs, settlement costs and fees, attorneys fees and any other expenses arising from any claim or lawsuit that may arise from any loss, damage or injury (including death) to me or my property resulting from or arising in connection with, or related to, my attendance at or participation in the Mid-Summer Youth All Comers Meet. I/we grant permission to the Meet Directors or their designee to act as guardian/spokesman with full authorization and power to authorize emergency medical treatment, including hospitalization and anesthesia, if medically necessary, for my/our son or daughter while at the site of the Mid-Summer Youth All Comers Meet. I/we understand that should a health emergency arise, I/we will be notified but if I/we cannot be reached by phone such medical treatment as is deemed necessary by medical personnel under the circumstances presented is hereby expressly authorized. 

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Signature - ATHLETE                                                     Signature - PARENT / GUARDIAN (Must be signed if athlete is under 18 years of age.)

Telephone: (_________)_____________________________  List allergies and current medications: ___________________________

Directions to Middletown High School: Traveling south/west on I-95 toward New Haven, CT, take Rt. 9 N just past Old Lyme, CT. Travel to Exit 11. Left off the ramp onto Rt. 155 W (Randolph Rd.). Travel 1.5  miles, right turn onto Hunting Hill Rd -- HS is about 1/2 mi. on the left.  From New York and southwest, I-95N toward New Haven, take left Exit 48 to merge onto I-91 N to exit 15 (Rt. 68), Yalesville. Turn right off the ramp onto 68 toward Durham/Middlefield. Left onto Rt. 17 N toward Middletown for several miles. Right onto 155E (Randolph Rd). Travel .7 mi. and turn left onto Hunting Hill Rd. HS is 1/2 mile on left. From North (I-84 or I-91) Travel toward Hartford, take 9S (if coming from northwest) or I-91 S toward New Haven. Take Rt. 9S toward Middletown. Take Exit 11, then left turn off the ramp onto 155W (Randolph Rd.) toward Durham. Travel 1.5  miles, then right turn onto Hunting Hill Rd. High school is 1/2 mile on left. Parking is on the right.