| Pre-registration: (ends 8/14/14) |
$20 by 8/14/14 $25 discount for groups of 5 or more. Please send all entry forms together. | | Regular | Registration: |
$25 after 8/14/14 | |
| Make checks payable to: Wise County Christian School | ||||
| Mail this form to: Wise County Christian School PO Box 3297 Wise Va 24293 | ||||
| Headphones are permitted on the course | Strollers are permitted on the course |
| For more info contact Amy Ketron, ayhopkins@hotmail.com, 276-210-7029 | Laura's 5K Run Male & Female Awards: Top Overall Age Groups (top 3) 15u, 16-19, 20-29, 30-39, 40-49, 50+ | 5K Walk (Untimed) Male & Female Awards: Age Groups (top 3) Untimed walk, no awards. |
| 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 EVENT: Laura's 5K Run | 5K Walk (Untimed) |
*** 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) |