6:00PM START 10k RUN/2mi walk FUN EVENING RACE!!! |
| Pre-registration: (ends 8-4-2012) |
$15.00- 10k run $10.00- walk | | Regular | Registration: |
$20.00- 10k run $10.00 -walk DOORPRIZES FOR BOTH WALKERS AND RUNNERS ONLY PRE-REGISTERED RUNNERS ARE GUARANTEED A SHIRT | |
| Make checks payable to: Christopher Todd Richardson Memorial Scholarship | ||||
| Mail this form to: CTR 10k 15191 Big Knob Bristol, Va 24202 | ||||
| ALL ENTRY FEES GOES DIRECTLY TO THE CTR MEMORIAL SCHOLARSHIP FUND WHICH BENEFITS COLLEGE STUDENTS FROM SOUTHWEST VA MAJORING IN GEOLOGY, ENVIRONMENTAL SCIENCE OR SOME OTHER ENERGY RELATED FIELD. HANDMADE POTTERY OVERALL AWARDS BY LOCAL ARTIST |
| Headphones are permitted on the course | Strollers are permitted on the course |
| For more info contact RD: JENNY NICHOLS 276-619-1489 jendenichols@mac.com ( subject heading: CTR 10k) | CHRISTOPHER TODD RICHARDSON MEMORIAL 10K Male & Female Awards: Overall (top 3) Masters (top 3) GrandMasters (top 3) Age Groups (top 3) ...19,20-24,25-29,30-34,35-39,40-44,45-49,50-54,55-59,60... |
| 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) |