Please print out and complete this form, then mail it to the address below. Please print legibly!
NAME ________________________________________________________________
MAILING ADDRESS _____________________________________________________
CITY _________________________ STATE ______ ZIP ________________
COUNTRY __________________________
DAYTIME PHONE __________________________________ EVENING PHONE __________________________________
E-MAIL ADDRESS ____________________________________________________________
DATE OF BIRTH (M/D/Y) ________________ GENDER (circle one): M / F
T-SHIRT SIZE (circle one): S M L XL
Comfortable per-mile training pace on a 5K run: _______________
(This pace will establish groups for the week.)
Anticipated average weekly mileage for the five weeks preceding arrival at camp: _____
If you plan to share a room with a specific individual, please provide roommate's name:
______________________________________________________________________
Are you a member of a running team or club? _________________________________
Are you a repeat camper? Yes / No If yes, most recent year you attended: _______
Referred by: _______________________________________
WAIVER: In case of injury or medical emergency, I hereby authorize the staff of Newport Running Camp to act
on my behalf according to their best judgment. I hereby waive and release Newport Running Camp,
Portsmouth Abbey School, and their principals, staff, and guests from any and all liability for any injury or illness incurred while at camp.
CAMPER'S SIGNATURE ____________________________________________________________________________________
IF UNDER AGE 18, SIGNATURE OF PARENT OR GUARDIAN IS REQUIRED:
__________________________________________________________________________________________________________
Please make your check or money order payable to Newport Running Camp. Your application and nonrefundable deposit of $100.00 should be mailed to: Newport Running Camp, 688 Broad Street, Shrewsbury, NJ 07702.