Church Hill Free Medical Clinic 5K


A.S. Derrick Park, 716 Ordinance Drive, Church Hill, TN

8/9/2014


9:00 am. Race to benefit the Church Hill Free Medical Clinic. Very nice finish inside the park. Race management and electronic timing by We Run Events.

Pre-registration:
(ends 8/7/14)
$20 until 8/7/14 | Regular
| Registration:
$25 after 8/7/14
Make checks payable to: Church Hill Free Medical Clinic
Mail this form to: Church Hill Free Medical Clinic
PO Box 166
Church Hill, TN 37642
Headphones are permitted on the course | Strollers are permitted on the course
For more info contact
Catherine Doerr, freeclinic@ofoneaccordministry.org
5K Run/Walk
Male & Female Awards:

Top Overall
Top Masters
Top GrandMasters

Age Groups (top 3)
14U, 15-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70+

Church Hill Free Medical Clinic 5K

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, XXL

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.

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


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