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
Portsmouth / Newport Running Camp to act
on my behalf according to their best judgment.
I hereby waive and release Portsmouth / 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
Portsmouth / Newport Running
Camp.
Your application and nonrefundable deposit of $100.00 should be mailed to:
Portsmouth / Newport Running Camp, PO Box 7207, Shrewsbury, NJ 07702.