| 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+ |
| 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, |
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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. |
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SIGNATURE_____________________________ DATE_____/_____/_____ (Parent signature if under the age of 18) |