8:30am - One Mile Fun Run |
| Pre-registration: (ends 05/04/13) |
$15 - 5K $5 - One Mile Fun Run | | Regular | Registration: |
$20 - 5k $10 - One Mile Fun Run | |
| SFTC King & Queen race: SFTC members receive preregistration discount | ||||
| Make checks payable to: Justin Foundation | ||||
| Mail this form to: PO Box 656 Damascus, VA 24236 | ||||
| Only preregistered runners are guaranteed a shirt. |
| Headphones are NOT permitted on the course | Strollers are NOT permitted on the course |
| For more info contact David Matlock (276)475-6043 | Justin Foundation 5K Scholarship Run Male & Female Awards: Overall (top 3) Masters (top 3) GrandMasters (top 3) Age Groups (top 3) ...15,16-20,21-25,26-30,31-35,36-40,41-45,46-50,51-55,56-60,60... |
| 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, |
|
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. STROLLERS ARE NOT ALLOWED ON THE RACE COURSE. PARTICPANTS USING HEADPHONES ARE NOT ALLOWED ON THE RACE COURSE. |
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SIGNATURE_____________________________ DATE_____/_____/_____ (Parent signature if under the age of 18) |