9th Annual Take Back the Night 5k


East Tennessee State University D.P. Culp Center Cave Patio for registration
, Johnson City, TN

3/23/2013


Registration will begin at 8:30am | Race will begin at 9:30am | Most of the proceeds will go to SANE (Sexual Assault Nurse Education).

Pre-registration:
(ends 03/15/13)
$14 Run/Walk | Regular
| Registration:
$16 Run/Walk
SFTC King & Queen race: SFTC members receive preregistration discount
Make checks payable to: ETSU Take Back the Night
Mail this form to: Kristen Feemster, East Tennessee State University, Counseling Center, P.O. Box 70724, Johnson City, TN 37614
All proceeds will benefit the Johnson City Medical Center's Sexual Assualt Nurse Examiners Program
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
ETSU OASIS at
OASIS@etsu.edu
423-439-4841
9th Annual Take Back the Night 5k
Male & Female Awards:

Top Overall
Top Masters
Top GrandMasters

Age Groups (top 3)
...19,20-24,25-29,30-34,35-39,40-44,45-49,50-54,55-59,60-64,65-69,70+

9th Annual Take Back the Night 5k

LAST NAME__________________________________ FIRST NAME_________________________ M.I._______

SEX____ DATE OF BIRTH____/____/____ AGE ON RACEDAY_____ E-MAIL____________________________

ADDRESS___________________________________________________________________________

CITY________________________ STATE_________ ZIP___________ PHONE (_______)_______-___________

RACE DAY EMERGENCY CONTACT (NAME AND PHONE)_________________________________________

*** CIRCLE SHIRT SIZE: SM, MD, LG, XL,

IN CONSIDERATION FOR ACCEPTING MY ENTRY IN THIS RACE, I FOR MYSELF, MY HEIRS, EXECUTORS AND ADMINISTRATORS, WAIVE AND RELEASE FOREVER ANY AND ALL RIGHTS AND CLAIMS FOR DAMAGES I MAY HAVE AGAINST THE ORGANIZERS AND SPONSORS OF THIS EVENT. I ALSO RELEASE THE ABOVE NAMED FOR ALL CLAIMS OF DAMAGE DEMANDS, AND ACTIONS IN ANY MANNER DUE TO ANY PERSONAL INJURIES, PROPERTY DAMAGE, OR DEATH SUSTAINED AS A RESULT OF MY TRAVELING TO AND FROM AND MY PARTICIPATION IN SAID RACE. I ATTEST AND VERIFY THAT I AM PHYSICALLY FIT AND HAVE SUFFICIENTLY TRAINED FOR THE COMPETITION OF THIS EVENT. IN FILLING OUT THIS FORM, I ACKNOWLEDGE I HAVE READ AND FULLY UNDERSTAND MY OWN LIABILITY AND ABILITY.

SIGNATURE_____________________________ DATE_____/_____/_____ (Parent signature if under the age of 18)


This entry form was generated with the SFTC Calendar Utility at www.runtricities.org