Big Blue Challenge 5K For Autism Awareness


Richlands High School, Richlands, VA

4/6/2013


8:30am- 5K
10am- Fun Run


Pre-registration:
(ends March 31, 2013)
$18 adults
$12 12 and under
| Regular
| Registration:
$20 everyone on raceday
Make checks payable to: RHS
Mail this form to: ATTN: Jenn Desrosiers
138 Tornado Alley
Richlands VA 24641
Headphones are permitted on the course | Strollers are NOT permitted on the course
For more info contact
jdesrosiers@tazewell.k12.va.us
Big Blue Challenge 5K For Autism Awareness
Male & Female Awards:

Top Overall
Top Masters
Top GrandMasters

Age Groups (top 3)
...10,11-19,20-28,29-37,38-46,47-55,56-64,60...

Big Blue Challenge 5K For Autism Awareness

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: YM, YL, 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.

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


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